Screening For Aspiration Risk Associated With Dysphagia in Acute Stroke

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Cochrane Database of Systematic Reviews
Screening for aspiration risk associated with dysphagia in acute

stroke (Review)
Boaden E, Burnell J, Hives L, Dey P, Clegg A, Lyons MW, Lightbody CE, Hurley MA, Roddam H,
McInnes E, Alexandrov A, Watkins CL
Boaden E, Burnell J, Hives L, Dey P, Clegg A, Lyons MW, Lightbody CE, Hurley MA, Roddam H, McInnes E, Alexandrov A,
Watkins CL.
Screening for aspiration risk associated with dysphagia in acute stroke.
Cochrane Database of Systematic Reviews 2021, Issue 10. Art. No.: CD012679.
DOI: 10.1002/14651858.CD012679.pub2.
www.cochranelibrary.com
Screening for aspiration risk associated with dysphagia in acute stroke (Review)
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 8
OBJECTIVES.................................................................................................................................................................................................. 9
METHODS..................................................................................................................................................................................................... 9
Figure 1.................................................................................................................................................................................................. 11
RESULTS........................................................................................................................................................................................................ 13
Figure 2.................................................................................................................................................................................................. 15
Figure 3.................................................................................................................................................................................................. 17
Figure 4.................................................................................................................................................................................................. 18
Figure 5.................................................................................................................................................................................................. 19
Figure 6.................................................................................................................................................................................................. 20
Figure 7.................................................................................................................................................................................................. 21
Figure 8.................................................................................................................................................................................................. 22
Figure 9.................................................................................................................................................................................................. 23
Figure 10................................................................................................................................................................................................ 24
DISCUSSION.................................................................................................................................................................................................. 24
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 27
ACKNOWLEDGEMENTS................................................................................................................................................................................ 27
REFERENCES................................................................................................................................................................................................ 28
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 35
DATA.............................................................................................................................................................................................................. 78
Test 1. Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004)................................................................................ 81
Test 2. Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001)................................................................................ 81
Test 3. Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007)................................................................................................ 81
Test 4. Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009)........................................................................... 81
Test 5. Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2...................................................................... 81
Test 6. Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016).............................................................................................. 81
Test 7. Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009)........................................................................... 82
Test 8. Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010).......................................................................... 82
Test 9. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Edmiaston (2014)............................................. 82
Test 10. Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swallow test - Huhn-Matesic (2015)...................... 82
Test 11. Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001).............................................................................. 82
Test 12. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia - Edmiaston (2014)........................................... 82
Test 13. Modified MASA (MMASA) Neurologist 1 - Antonios (2010).................................................................................................... 83
Test 14. Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016).......................................................................... 83
Test 15. Clinical examination - Daniels (1997).................................................................................................................................... 83
Test 16. Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010).......................................................................... 83
Test 17. Nurse Dysphagia Screen - Cummings (2015)........................................................................................................................ 83
Test 18. Modified MASA (MMASA) Neurologist 2 - Antonios (2010).................................................................................................... 83
Test 19. Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000).............................................................................................. 84
Test 20. Bedside swallow test - WST only - Lim (2001)....................................................................................................................... 84
Test 21. Chinese version of the modified SSA original 8 items - Jiang (2019)................................................................................... 84
Test 22. Chinese version of the modified SSA reduced 6 items - Jiang (2019).................................................................................. 84
Test 23. Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) - Bravata (2009)................................................ 84
Test 24. Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013).................................................................................................... 84
Test 25. 2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008).................................................................... 85
Test 26. Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels (2016)........................................................ 85
Test 27. Gag function - Test3 - Perry (2001)........................................................................................................................................ 85
Test 28. DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera (2018).................................................................. 85
Screening for aspiration risk associated with dysphagia in acute stroke (Review) i
Informed decisions.
Test 29. DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018)......................................................................... 85
Test 30. Gag function - Test4 - Perry (2001)........................................................................................................................................ 85
Test 31. 2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008)....................................................................... 86
Test 32. Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen - Mulheren (2019)........................................... 86
Test 33. Nursing Screening Tool - Bravata (2009)............................................................................................................................... 86
Test 34. Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish version (T-BJH) - Eren (2019).............................. 86
Test 35. Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011).............................................................................................. 86
Test 36. TOR-BSST water swallow item - Martino (2014).................................................................................................................... 86
Test 37. Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005)............................................................................. 87
Test 38. Index taxonomy - water only................................................................................................................................................. 87
Test 39. Index taxonomy - water plus other consistencies................................................................................................................. 87
Test 40. Index taxonomy - other.......................................................................................................................................................... 87
Test 41. Outcome - aspiration.............................................................................................................................................................. 88
Test 42. Outcome - dysphagia.............................................................................................................................................................. 88
Test 43. Reference test - Expert Assessment and MASA..................................................................................................................... 89
Test 44. Reference test - FEES.............................................................................................................................................................. 89
Test 45. Reference test - VF.................................................................................................................................................................. 89
Test 46. HCP - nurse.............................................................................................................................................................................. 90
Test 47. HCP - other.............................................................................................................................................................................. 90
ADDITIONAL TABLES.................................................................................................................................................................................... 90
APPENDICES................................................................................................................................................................................................. 93
WHAT'S NEW................................................................................................................................................................................................. 101
HISTORY........................................................................................................................................................................................................ 101
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 102
DECLARATIONS OF INTEREST..................................................................................................................................................................... 102
SOURCES OF SUPPORT............................................................................................................................................................................... 102
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 102
INDEX TERMS............................................................................................................................................................................................... 102
Screening for aspiration risk associated with dysphagia in acute stroke (Review) ii
Informed decisions.
[Diagnostic Test Accuracy Review]
Screening for aspiration risk associated with dysphagia in acute stroke
Elizabeth Boaden1, Jane Burnell2, Lucy Hives2, Paola Dey3, Andrew Clegg2, Mary W Lyons4, C Elizabeth Lightbody5, Margaret A Hurley2,
Hazel Roddam6, Elizabeth McInnes7, Anne Alexandrov8, Caroline L Watkins5
1Faculty of Health and Care , University of Central Lancashire , Preston, UK. 2Faculty of Health and Care, University of Central Lancashire ,
Preston, UK. 3Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK. 4Liverpool School of Tropical Medicine, Liverpool, UK.
5Faculty of Health and Care, University of Central Lancashire, Preston, UK. 6Faculty of Allied Health and Well-being, University of Central
Lancashire, Preston, UK. 7Nursing Research Institute, Australian Catholic University, Sydney, Australia. 8University of Tennessee Health
Science Center (UTHSC), Memphis, Tennessee, USA
Contact: Elizabeth Boaden, eboaden1@uclan.ac.uk.
Editorial group: Cochrane Stroke Group.

Publication status and date: New, published in Issue 10, 2021.
Citation: Boaden E, Burnell J, Hives L, Dey P, Clegg A, Lyons MW, Lightbody CE, Hurley MA, Roddam H, McInnes E, Alexandrov A,
Watkins CL. Screening for aspiration risk associated with dysphagia in acute stroke. Cochrane Database of Systematic Reviews 2021, Issue
10. Art. No.: CD012679. DOI: 10.1002/14651858.CD012679.pub2.
ABSTRACT
Background
Stroke can affect people’s ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest
infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased
likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces
risk of these difficulties.
Objectives
Primary objective
• To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration
associated with dysphagia in people with acute stroke
Secondary objectives
• To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia
- Patient demographics (e.g. age, gender)
- Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening
tools are identified
- Definition of dysphagia used by the study
- Level of training of nursing staff (both grade and training in the screening tool)
- Low-quality studies identified from the methodological quality checklist
- Type and threshold of index test
- Type of reference test
Screening for aspiration risk associated with dysphagia in acute stroke (Review) 1
Informed decisions.
Search methods
In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA)
database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted
experts in the field to identify any ongoing studies and those potentially missed by the search strategy.
Selection criteria
We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other
healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults
with acute stroke admitted to hospital.
Data collection and analysis

Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity
and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements.
The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool.
We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as
sensitivities and specificities for the index tests.
Main results
Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included
studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other
consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and
from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and
from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to
86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference,
six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome
of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one
screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)).
We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across
all three applicability domains.
No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water
swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the
Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening
Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However,
clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes,
which limits the estimates of reliability of screening tests.
Authors' conclusions
We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least
one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve
the accuracy and clinical utility of bedside screening tools.
PLAIN LANGUAGE SUMMARY
Screening for aspiration risk associated with dysphagia in acute stroke
Question
How accurate are swallow screening tools for detecting when food and drink enter the airway in people with acute stroke?
Background
Stroke often affects a person’s ability to swallow, allowing food and drink into the airway. This can cause choking, chest infection,
malnutrition, dehydration, and reduced rehabilitation, with increased risk of anxiety, depression, discharge to a care home, and death.
Early identification and management of disordered swallowing through the most accurate testing reduces these risks. If the test fails
to identify swallowing difficulties, the person will continue oral intake and may experience the difficulties identified above. If the test
incorrectly identifies swallowing difficulties, the person may not be given anything to eat or drink, significantly impacting quality of life,
until a more detailed assessment is undertaken (usually the next day).
Study characteristics
Informed decisions.
We identified 25 studies that used a total of 37 tools. Seven tools did not use water or other consistencies, 24 used only water, and six
considered water and other consistencies.
Key results
We were unable to identify a tool that could accurately identify everyone with food and drink entering their airway, as well as detect
all those who definitely did not. Many studies involved different healthcare professionals, food and fluid testing consistencies, and time
between stroke onset and the screening test, so it is unclear which tool is best. We were unable to directly compare the different tools
because most studies used different methods.
We were able to identify the tools most able to detect people with and without risk of swallowing difficulties from studies with good quality
evidence. The best combined water swallow and instrumental test was the Bedside Aspiration test, the best water plus other consistencies
tool was the Gugging Swallowing Screen, and the best water only tool was the Toronto Bedside Swallowing Screening Test. However,
clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes.
Quality of the evidence
Most included studies were poorly conducted or were unclear in reporting what they did (i.e. unclear or high risk of bias).
Conclusion
We were unable to identify a single tool with combined high levels of accuracy and good quality evidence. However, we are able to offer
recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of swallow screening tools.
Informed decisions.
SUMMARY OF FINDINGS
Summary of findings 1. Review criteria and findings
Review question What is the diagnostic accuracy of screening tools for aspiration risk associated with dysphagia in
acute stroke?
Importance A simple and reliable screening tool for identification of aspiration associated with dysphagia
would reduce diagnostic delay and the risk of developing pneumonia in acute stroke patients
Patients/population Patients (over the age of 18) who have been admitted to an acute hospital setting, where there is
a clinical diagnosis of stroke. Patients with subarachnoid haemorrhage were excluded from the
study
Settings Stroke units or hospital wards where acute stroke patients are admitted
Index tests Bedside swallowing screening tools carried out by healthcare professionals (excluding SLTs)
Reference standards Expert assessment, including the MASA

VF
FEES
Studies 25 studies were included, 4 of which are presented as narratives (with no accuracy statistics report-
ed). The included studies reported 37 screening tests
Risk of bias Overall judgement: poor quality for the majority of studies – only 6 studies were at low risk across
all 4 risk of bias domains, and 2 studies were at low risk of bias for 3 domains
Patient selection bias: high risk = 12 studies; unclear risk = 11 studies; low risk = 2 studies
Index test interpretation bias: high risk = 14 studies; unclear risk = 10 studies; low risk = 1 study
Reference standard interpretation bias: high risk = 16 studies; unclear risk = 8 studies; low risk = 1
study
Flow and timing selection bias: high risk = 13 studies; unclear risk = 6 studies; low risk = 6 studies
Applicability concern Concerns regarding patient selection: high risk = 16 studies; unclear risk = 4 studies; low risk = 5
studies
Concerns regarding index test: high risk = 20 studies; unclear risk = 4 studies; low risk = 1 study
Concerns regarding reference standard: high risk = 22 studies; unclear risk = 3 studies; low risk = 0
studies
Overall findings The best performing swallow screening tools were the Combined WST and Oxygen Saturation
Test (Lim 2001a), GUSS (Trapl 2007b), and TOR-BSST (Martino 2009). The best water only swallow
screening test was the TOR-BSST (Martino 2009). All demonstrate a combined highest sensitivity
and specificity and low risk of bias across all domains. These tools may be considered useful in clin-
ical practice
The water plus various consistencies (n = 6) performed better than the water-only tools in terms of
sensitivity and specificity
Only a few studies (e.g. GUSS) (Trapl 2007b) gave direction on what food and drink consistencies
should be given to an individual following the screen
Informed decisions.
The quality of evidence varied. Studies often failed to distinguish between dysphagia and aspi-
ration as the primary outcome. Some did not identify the time interval between stroke onset or
admission to hospital and the screen, or the time interval between index test and reference test.
Training required by different healthcare professionals to implement the screening tool was not re-
ported well. This has implications for future research
FEES: fibreoptic endoscopic evaluation of swallowing.

MASA: Mann Assessment of Swallowing Ability.
SLT: speech and language therapist.
VF: videofluoroscopy.
WST: water-swallowing test.
Summary of findings 2. Screening tests
Screening test N participants Reference stan- Diagnostic estimates Implications

(studies) dard (95% CI)
Water-only tests 2914 (13)
Toronto Bedside Swallowing 24 (1) VFSS Sens = 1.00 (0.75 to 1.00) Insufficient evidence to al-
Screening Test (TOR-BSST): Mar- spec = 0.64 (0.31 to 0.89) low firm conclusions
tino 2009 Study 1
Acute Stroke Dysphagia Screen- 300 (1) Expert assess- Sens = 0.95 (0.87 to 0.99) Large study with unclear
ing (ASDS) Aspiration: Edmias- ment and MASA spec = 0.69 (0.62 to 0.75) risk of bias and low applic-
ton 2010 ability concerns
Barnes-Jewish Hospital-Stroke 223 (1) VFSS Sens = 0.95 (0.86 to 0.99) Large study with un-
Dysphagia Screen (BJH-SDS) As- spec = 0.50 (0.42 to 0.58) clear/low risk of bias and
piration: Edmiaston 2014 low applicability concerns
Edith-Huhn-Matesic Bedside As- 52 (1) Expert assess- Sens = 0.94 (0.71 to 1.00) Insufficient evidence to al-
piration Screen (EHMBAS) fol- ment and MASA spec = 0.77 (0.60 to 0.90) low firm conclusions
lowed by simple water swallow
test: Huhn-Matesic 2015
Barnes-Jewish Hospital-Stroke 225 (1) VFSS Sens = 0.94 (0.88 to 0.98) Large study with low risk
Dysphagia Screen (BJH-SDS) spec = 0.66 (0.57 to 0.75) of bias and low applicabili-
Dysphagia: Edmiaston 2014 ty concerns.
Rapid Aspiration Screening 250 (1) VFSS Sens = 0.93 (0.77 to 0.99) Large study with low risk
for Suspected Stroke (RAS3): spec = 0.43 (0.36 to 0.50) of bias and low applicabili-
Daniels 2016 ty concerns.
Clinical examination: Daniels 59 (1) VFSS Sens = 0.92 (0.75 to 0.99) Insufficient evidence to al-
1997 spec = 0.64 (0.45 to 0.80) low firm conclusions
Acute Stroke Dysphagia Screen- 300 (1) Expert assess- Sens = 0.91 (0.83 to 0.96) Large study with unclear
ing (ASDS) Dysphagia: Edmias- ment and MASA spec = 0.75 (0.68 to 0.80) risk of bias and low applic-
ton 2010 ability concerns
Nurse Dysphagia Screen: Cum- 49 (1) Expert assess- Sens = 0.89 (0.65 to 0.99) Insufficient evidence to al-
mings 2015 ment and MASA spec = 0.90 (0.74 to 0.98) low firm conclusions
Bedside swallow test - WST on- 50 (1) FEES Sens = 0.85 (0.65 to 0.96) Insufficient evidence to al-
ly: Lim 2001 spec = 0.75 (0.53 to 0.90) low firm conclusions
Informed decisions.
Chinese version of the modi- 127 (1) Expert assess- Sens = 0.83 (0.71 to 0.91) Insufficient evidence to al-
fied SSA – original 8 items: Jiang ment and MASA spec = 0.59 (0.46 to 0.71) low firm conclusions
2019
Chinese version of the modified 127 (1) Expert assess- Sens = 0.81 (0.69 to 0.90) Insufficient evidence to al-
SSA – reduced 6 items: Jiang ment and MASA spec = 0.64 (0.51 to 0.76) low firm conclusions
2019
2-step swallowing provocation 100 (1) FEES Sens = 0.74 (0.63 to 0.83) Insufficient evidence to al-
test (SPT) - step 1 - 0.4 mL: War- spec = 1.00 (0.82 to 1.00) low firm conclusions
necke 2008
Rapid Aspiration Screening for 250 (1) VFSS Sens = 0.72 (0.53 to 0.87) Large study with low risk
Suspected Stroke (RAS3) - WST spec = 0.60 (0.53 to 0.66) of bias and low applicabili-
only: Daniels 2016 ty concerns.
Gag function - Test3: Perry 2001 22 (1) Expert assess- Sens = 0.71 (0.42 to 0.92) Insufficient evidence to al-
Study 1 ment and MASA spec = 0.63 (0.24 to 0.91) low firm conclusions
DePaul Hospital Swallow 226 (1) Expert assess- Sens = 0.70 (0.55 to 0.83) Large study with unclear
Screener (DHSS) Aspiration: Be- ment and MASA spec = 0.90 (0.85 to 0.94) risk of bias and unclear ap-
hera 2018 plicability concerns
DePaul Hospital Swallow 225 (1) Expert assess- Sens = 0.68 (0.55 to 0.80) Large study with unclear
Screener (DHSS) Dysphagia: Be- ment and MASA spec = 0.93 (0.88 to 0.96) risk of bias and unclear ap-
hera 2018 plicability concerns
Gag function - Test4: Perry 2001 157 (1) Expert assess- Sens = 0.67 (0.57 to 0.76) Insufficient evidence to al-
Study 1 ment and MASA spec = 0.78 (0.65 to 0.88) low firm conclusions
2-step swallowing provocation 100 (1) FEES Sens = 0.49 (0.38 to 0.61) Insufficient evidence to al-
test (SPT) - step 2 - 2.0 mL: War- spec = 1.00 (0.82 to 1.00) low firm conclusions
necke 2008
Johns Hopkins Hospital Brain 48 (1) VFSS Sens = 0.46 (0.28 to 0.66) Insufficient evidence to al-
Rescue Unit Modified 3 oz Swal- spec = 1.00 (0.83 to 1.00) low firm conclusions
low Screen: Mulheren 2019
Water plus consistencies tests 412 (5)
Registered Dietitian (RD) Dys- 32 (1) Expert assess- Sens = 1.00 (0.69 to 1.00) Insufficient evidence to al-
phagia Screening tool: Huh- ment and MASA spec = 0.86 (0.65 to 0.97) low firm conclusions
mann 2004
Gugging Swallowing Screen 30 (1) FEES Sens = 1.00 (0.77 to 1.00) Insufficient evidence to al-
(GUSS) - Group2: Trapl 2007 spec = 0.69 (0.41 to 0.89) low firm conclusions
Standardized Swallowing As- 68 (1) Expert assess- Sens = 0.97 (0.86 to 1.00) Insufficient evidence to al-
sessment tool (SSA) – Test2: Per- ment and MASA spec = 0.90 (0.74 to 0.98) low firm conclusions
ry 2001 Study 1
Nursing Bedside Dysphagia 75 (1) Expert assess- Sens = 0.97 (0.90 to 1.00) Insufficient evidence to al-
Screen (NBDS): Campbell 2016 ment and MASA spec = 0.75 (0.35 to 0.97) low firm conclusions
Standardized Swallowing As- 161 (1) Expert assess- Sens = 0.94 (0.87 to 0.98) Insufficient evidence to al-
sessment tool (SSA) - Test1: Per- ment and MASA spec = 0.75 (0.63 to 0.84) low firm conclusions
ry 2001 Study 1
Informed decisions.
Nursing Bedside Swallowing 46 (1) Expert assess- Sens = 0.75 (0.35 to 0.97) Insufficient evidence to al-
Screen (NBSS): Ellis 2013 ment and MASA spec = 0.89 (0.75 to 0.97) low firm conclusions
Other tests 627 (5)
Bedside aspiration - Combined 50 (1) FEES Sens = 1.00 (0.87 to 1.00) Insufficient evidence to al-
WST & Oxygen Saturation: Lim spec = 0.71 (0.49 to 0.87) low firm conclusions
2001
Emergency Department (ED) 84 (1) Expert assess- Sens = 0.96 (0.86 to 0.99) Insufficient evidence to al-
dysphagia screen: Turn- ment and MASA spec = 0.56 (0.38 to 0.72) low firm conclusions
er-Lawrence 2009
Modified MASA (MMASA) Neurol- 150 (1) Expert assess- Sens = 0.93 (0.82 to 0.98) Insufficient evidence to al-
ogist 1: Antonios 2010 ment and MASA spec = 0.86 (0.78 to 0.93) low firm conclusions
Modified MASA (MMASA) Neurol- 150 (1) Expert assess- Sens = 0.87 (0.75 to 0.95) Insufficient evidence to al-
ogist 2: Antonios 2010 ment and MASA spec = 0.84 (0.76 to 0.91) low firm conclusions
Oxygen saturation ≥ 2% - Test2 53 (1) VFSS Sens = 0.87 (0.60 to 0.98) Insufficient evidence to al-
for Aspiration: Smith 2000 spec = 0.39 (0.24 to 0.57) low firm conclusions
Stroke Severity using National 101 (1) Expert assess- Sens = 0.79 (0.63 to 0.90) Insufficient evidence to al-
Institutes of Health Stroke Scale ment and MASA spec = 0.68 (0.55 to 0.79) low firm conclusions
(NIHSS): Bravata 2009
Nursing Screening Tool: Bravata 39 (1) Expert assess- Sens = 0.29 (0.08 to 0.58) Insufficient evidence to al-
2009 ment and MASA spec = 0.84 (0.64 to 0.95) low firm conclusions

sens: sensitivity.
spec: specificity.
VFSS: videofluoroscopic swallowing study.
Informed decisions.
BACKGROUND not), although it is acknowledged there may be different levels of

severity of swallowing difficulty and subsequent management. A
Stroke is the second most common cause of death worldwide positive test should lead to a referral for more definitive assessment
(Katan 2018), and it is the largest cause of complex preventable to confirm the presence of dysphagia or not, when this is available.
disability in adults (WHF 2016). Over 13.7 million new strokes Screening tools also need to be acceptable and feasible for use
are reported globally each year (Johnson 2019), with a projected in people with a range of sequelae following stroke (e.g. different
increase in incidence due to an ageing population (Avan 2019). levels of consciousness, cognitive levels, postural difficulties).
Screening tools must be undertaken prior to any oral intake and
The reported incidence of dysphagia (swallowing difficulties) therefore need to be administered by staff members who are at the
following acute stroke varies between 37% and 78% (Martino bedside throughout a 24-hour period.
2005); this is related to type and severity of stroke and individual
characteristics (e.g. comorbidities). It is also related to the type There is wide variation in available screening tools. Some swallow
of diagnostic assessment used to detect dysphagia and time from screening tools rely on questionnaires, whilst others use food and
admission to that assessment. Dysphagia may lead to aspiration, drink as testing materials. Swallow screening tools vary in the
defined as food or fluid entering the airway below the level of types of foods and fluids tested. Water swallow tools, such as the
the vocal cords (Blitzer 1988), then into the trachea. People with Standardised Swallow Assessment (Perry 2001 Study 1), or the
dysphagia are three times, and those with aspiration 11 times, more Massey Bedside Swallow Screen (Massey 2002), are very similar in
likely to develop pneumonia (Kumar 2010; Rofes 2011), which is a that they offer people different quantities of fluids from assorted
significant cause of further morbidity leading to increased hospital utensils; some studies use water plus a range of consistencies
stay and risk of death (Intercollegiate Stroke Working Party 2012). to prescribe food and drink consistency management plans. This
group of swallow screening tests are more dissimilar from each
Stroke-associated pneumonia is more common if identification other as they offer a variety of food and drink, give different
of dysphagia is delayed because of aspiration of food, drink, consistencies, trial different volumes, and alter the order in which
medications, and oral secretions (Bray 2016). Therefore, early foods and drinks are offered. One concern is that some of these
screening for dysphagia may be an important avenue for reducing tools have been developed and assessed with various reference
deaths from acute stroke (Bray 2016; Donovan 2013). tests and different professional groups not routinely available at
the bedside, which limits their clinical utility.
Internationally, different clinical guidelines are available for
detecting swallowing difficulties in acute stroke. Identification of There is no universally accepted screening tool for identification
dysphagia is a criterion that is considered for obtaining Stroke Unit and management of aspiration associated with dysphagia, and
accreditation by the European Stroke Organisation. Within the UK, a wide range of screening tests are used in clinical practice
Europe, Canada, the USA, and Australia, guidelines state that on throughout the world. A false-negative result is much worse than
admission to hospital, people with acute stroke should have their a false-positive result. If the swallow screening test fails to identify
swallowing screened promptly following admission (European swallowing difficulties, the person will continue oral intake and
Stroke Organisation 2015; Intercollegiate Stroke Working Party may experience the difficulties identified above. If the swallow
2016; National Stroke Foundation 2010; Powers 2019; Teasell 2019). screening test erroneously identifies swallowing difficulties, the
patient is placed 'nil by mouth', with significant impact on quality of
Diagnostic methods such as videofluoroscopy (VF) and fibreoptic
life, until the SLT undertakes a more detailed assessment (usually
endoscopic evaluation of swallowing (FEES) are available.
the next day). So a bedside swallow screening tool should be
However, these methods have significant limitations when used
chosen while taking into account this simple clinical reality. Hence,
for early identification of dysphagia in acute stages of stroke.
there is a need to identify the most clinically useful screening test
Limitations may be patient specific (patients may be unable to
or tools that most accurately identify the presence or absence of
comply with instructions due to poor posture, cognition, medical
aspiration associated with dysphagia, and to prescribe a food and
state, or fluctuating swallowing ability); organisational (speech and
drink consistency management plan for individuals with aspiration
language therapists (SLTs) may not be available in the acute setting,
to improve their medical, social, and psychological outcomes.
and in most hospitals, instrumental examinations such as VF and
FEES can be requested only after SLT evaluation; furthermore, not Target condition being diagnosed
all staff are trained to interpret the results of these reference tests);
or procedural (specialist equipment is not available in all acute Aspiration risk associated with dysphagia in people who have had
settings) (Boaden 2011). Therefore, screening tools are needed to an acute stroke.
identify those likely to have dysphagia, who might be at greater risk
of aspiration, so that interventions can be put in place to reduce Index test(s)
morbidity until access to specialist equipment and staff is available In this review, bedside swallowing screening tests not administered
for assessment and/or until the patient is fit enough to undergo by SLTs are the index tests. A wide range of index tests (swallow
the procedures. These screening tools are called bedside swallow screening tests) are used at the bedside by healthcare professionals
screening tools. for recognition or determination of whether the patient is at risk of
Bedside swallow screening tools must be quick and easy to aspirating food and fluids.
administer. To be clinically useful, screening tools must accurately
Clinical pathway
identify those with dysphagia with its associated risk of aspiration
(sensitivity), without leading to unnecessary restrictions (e.g. Bedside swallow screening tests are commonly used in the typical
withholding food and drinks) for those who do not have dysphagia care pathway in compliance with clinical guidelines for stroke.
(specificity). The outcome of a screening test is binary (present or However, there are varying degrees of compliance. Usually these
Informed decisions.
tests are implemented by allied healthcare professionals (mainly accepted delays longer than 24 hours between the index test and
nurses) following admission to the acute care sector. Patients who the reference standard (Daniels 2012). The results of this review
are identified as at risk of swallowing difficulties are often placed will help guide policy makers and healthcare workers in acute
'nil by mouth' while awaiting an expert assessment or a further hospital settings on selection of the most appropriate bedside
reference test. The care pathway for patients who have a negative swallow screening test from those currently available and might
test result usually allows patients to continue to eat and drink also identify the research agenda going forward.
orally.
OBJECTIVES
Prior test(s)
Primary objective
No tests to assess swallowing are conducted on patients before
hospital admission. • To determine the diagnostic accuracy and the sensitivity and
specificity of bedside screening tests for detecting risk of
Role of index test(s) aspiration associated with dysphagia in people with acute
Index tests, that is, bedside screening tests not administered by stroke
SLTs, have the potential to improve the identification of people
with risk of aspiration associated with dysphagia following stroke.
Secondary objectives
Therefore, these tests may reduce the need for SLT evaluation and • To assess the influence of the following sources of heterogeneity
for more complex, invasive, and more expensive imaging methods, on the diagnostic accuracy of bedside screening tools for
such as VF, FEES, or scintigraphy, which may not be available in dysphagia
some healthcare settings. ◦ Patient demographics (e.g. age, gender)
◦ Time post stroke that the study was conducted (from
Alternative test(s)
admission to 48 hours) to ensure only hyperacute and acute
Other index tests include questionnaires that rely on self- stroke swallow screening tools are identified
reported dysphagia symptoms. However, these tools, for example, ◦ Definition of dysphagia used by the study
the Sydney Swallow Questionnaire (SSQ) and the Swallowing ◦ Level of training of nursing staff (both grade and training in
Disturbance Questionnaire (SDQ), were used or designed and the screening tool)
validated for use in patient populations such as those with head
◦ Low-quality studies identified from the methodological
and neck cancer or Parkinson’s disease. These are not considered
quality checklist
in this review.
◦ Type and threshold of index test
Rationale ◦ Type of reference test
We reviewed the diagnostic accuracy of currently available swallow METHODS
screening tests. A systematic review of published evaluations of
these screening tests will assist practitioners to identify those that Criteria for considering studies for this review
have undergone rigorous development and testing. This review will
also identify gaps in evidence for further research. Types of studies
We considered single-gate and two-gate studies if they compared
Healthcare professionals within acute stroke care settings are
the accuracy of a bedside screening tool administered by
responsible for deciding which bedside swallow screening test
nursing staff or other healthcare professionals (excluding SLTs)
they will use to detect people at risk of aspiration associated
with identified reference tests (VF, FEES, scintigraphy, expert
with dysphagia in adult acute stroke patients. When a bedside
assessment). We applied no restrictions in terms of language of
swallow screening test is considered, a test with high sensitivity and
publication.
specificity is paramount. False-negative results may lead to serious
consequences within the clinical context, as continued oral intake Participants
may precipitate aspiration pneumonia and death. High specificity is
also beneficial, as false-positive results may result in patients being We included studies if they involved adults (aged 18 and over)
designated ‘nil by mouth’ and provided with clinically assisted who had been admitted to an acute hospital setting with a clinical
nutrition and hydration unnecessarily. This adversely affects the diagnosis of stroke. We considered studies that were inclusive
well-being of the patient and incurs unnecessary costs. However, of people with subarachnoid haemorrhage and we excluded
false-positive results are less dangerous, in that usually an SLT will this sample subgroup from the analysis, when possible. We
see the patient within 24 hours. excluded studies that included only patients with subarachnoid
haemorrhage. We also excluded studies that admitted patients with
A recent systematic review of bedside swallow screening tests trauma.
provided a descriptive analysis of the different elements within
screening tests but did not compare these with a reference standard Index tests
(Almeida 2015). Other reviews have not specifically focused on We included studies if they evaluated a bedside swallow screening
a stroke population (Brodsky 2016; O'Horo 2015), have included test, used by nursing staff or other healthcare professionals
studies in which screening was not undertaken in a timely manner (excluding SLTs who have expert knowledge in this area), for
(Schepp 2012), have focused on individual clinical determinants recognition or determination of whether patients were at risk of
or behaviours associated with aspiration (Daniels 2012), have aspiration associated with dysphagia.
reviewed only multi-consistency tests (Benfield 2020), or have
Informed decisions.
Target conditions Library; MEDLINE Ovid (from 1946); Embase Ovid (from 1980); the
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
We included studies if they reported the accuracy of the bedside
EBSCO (from 1937 onward), and the Health Technology Assessment
screening tool for identification of the risk of aspiration owing to
(HTA) Database via the Centre for Reviews and Dissemination
dysphagia post stroke.
(University of York). The search strategy for MEDLINE is presented
Reference standards in Appendix 1 and was adapted for CENTRAL (Appendix 2), Embase
(Appendix 3), CINAHL (Appendix 4), and HTA (Appendix 5).
We included studies if a bedside swallow screening test, carried
out by nursing staff or other healthcare professionals, was Searching other resources
compared with VF, FEES, scintigraphy, or an expert assessment.
We checked the reference lists of all included studies, and we
Videofluoroscopy is an X-ray video of swallowing, allowing the
performed a cited reference search using Science Citation Index, to
swallow to be analysed in real time. FEES involves insertion
identify additional relevant studies and systematic reviews. We also
of a fibreoptic flexible endoscope that is passed through the
contacted experts in the field to identify ongoing studies and those
nasal passages to view the throat pre-swallows and post-
potentially missed by the search strategy.
swallows for secretion management, residue, and aspirated
material. Scintigraphy uses radioisotopes that are swallowed, We searched targeted grey literature sources, which we identified
and the emitted radiation is captured by external detectors from the the Canadian Agency for Drugs and Technologies in Health
(gamma cameras) to form images of swallowed material. Expert (CADTH) Grey Matters document (CADTH 2018). A full list of the grey
assessments included assessments conducted by dysphagia- literature sources searched is displayed in Appendix 6.
trained professionals such as SLTs. All reference standards are
not equally valid and available (the SLT is not usually available Data collection and analysis
in the acute setting and is not available 24 hours each day and
seven days a week), and some procedures are more invasive than Selection of studies
others. Expert assessment was included as a reference standard Two review authors from the team (EB, JB, HR, DD) independently
owing to the lack of immediate access to imaging or instrumental screened all titles and abstracts identified by the electronic
assessment in many centres, and to the inability of some patients to database searches and excluded duplications and irrelevant
co-operate with these assessments. However, expert assessments records. Conflicts were resolved by involvement of a third
have limitations in their ability to identify at bedside those patients review author (PD, AA). We then obtained full-text articles for
who have swallowing difficulties owing to silent aspiration when the remaining studies, which were independently assessed for
the patient demonstrates no clinical signs of aspiration. inclusion by two review authors (EB, ML, HR, PD) using the
eligibility criteria described above. Disagreements were resolved
Search methods for identification of studies by consensus meetings, with arbitration provided by a third review
Electronic searches author (AA) who had not initially reviewed the paper. When multiple
papers used the same cohort of patients, we used the paper
The search strategy used was developed with the help of with the most complete and up-to-date data. When we identified
the Cochrane Stroke Group Information Specialist. We searched relevant conference abstracts, we looked for the corresponding full-
relevant electronic databases for eligible diagnostic studies from text article. If we found no full-text article, we contacted the authors
inception until 9 December 2019: the Cochrane Central Register of the conference abstract. We excluded conference abstracts with
of Controlled Trials (CENTRAL; 2019, Issue 12), in the Cochrane insufficient data to calculate the 2 × 2 table. The selection process
is detailed in the PRISMA flow diagram in Figure 1.
Informed decisions.
Figure 1. PRISMA flow diagram.
Informed decisions.
Figure 1. (Continued)
Data extraction and management remained unavailable, we included the study in the review as a
narrative study.
Two review authors (JB, EM) designed a bespoke data extraction
form to collect details from the included studies. We piloted the Data from a single study were used only once in each analysis. We
form on other diagnostic accuracy studies related to acute stroke checked all studies to see if all patients were included, or if the
management that are beyond the scope of this review. For each number of patients was fixed, a priori in the design, from a condition
study, we extracted information related to characteristics of the (from the reference test) or from the index test. If the numbers
study, the patient population, index tests, reference standards, and of patients were fixed, the formulae for sensitivity and specificity
any relevant outcomes. would be different. No included studies used such numbers fixed a
priori.
Among a group of review authors (JB, AC, LH, CEL, ML, CW), two
independently extracted the data to ensure adequate reliability and Pooling of sensitivity and specificity results was intended for each
quality. These two review authors then met to agree on final data index test. However, due to the small number of studies using the
extractions for each included study. When there was disagreement same index test (three or fewer), we did not perform any meta-
between the two review authors, a third review author from the analyses of diagnostic accuracy data. Pooling of screening tests
group acted as an arbitrator. Once data extraction was complete, by general categories was performed as part of the descriptive
we entered the information into RevMan 5 (Review Manager 2014). analysis, presented along with sensitivity and specificity.
Assessment of methodological quality Investigations of heterogeneity
Two review authors from the group (JB, AC, LH, CEL, ML, Possible co-variates of interest were patient demographics (e.g.
CW) independently reviewed the methodological quality of each age, gender), time post stroke that the study was conducted,
included study, using criteria from the Quality Assessment of and level of training of nursing staff. However, the potential
Studies of Diagnostic Accuracy (QUADAS-2) tool, as recommended influence of these co-variates could not be investigated due to
by Cochrane (Appendix 7). As with previous diagnostic test accuracy the small number of studies for each index test. The definitions
reviews (Gupta 2016), we changed the QUADAS-2 question "Was a of dysphagia used by the study could have been grouped, and
case-control design avoided?" to "Was a two-gate design avoided?". the type and quality of the reference test, as well as the type
of index test, investigated as sources of heterogeneity. For the
We piloted the QUADAS-2 to promote agreement in interpretation
same reason, no subgroup analyses were performed involving age,
within the team. We resolved disagreements with a third review
gender, time post stroke of the index test, or index test type, and
author. We rated the QUADAS-2 criteria as ’yes’, ’no’, or ’unclear’
whether there had been a significant change in the participant’s
for each included study. As stated in our protocol, guidance
condition between performance of index and reference tests. Index
indicates that criteria 1, 2, 3, and 9 should receive particular
tests were pooled by broad categories (by index test type, by
attention regarding definitions used as the basis for decisions.
healthcare professional (HCP), by outcome, and by reference test),
The other criteria are more self-explanatory with regards to their
and graphical comparisons were made. We therefore performed
interpretation.
only a narrative review running exploratory analysis in RevMan 5 to
Statistical analysis and data synthesis show graphically if the co-variates of interest are likely to be related
to test accuracy, displayed using forest plots and SROC plots.
From each index test, the parameters of interest were sensitivity
and specificity. For a majority of index tests, these were calculated Sensitivity analyses
from the 2 × 2 tables. For other index tests, information from
We did not carry out any sensitivity analyses due to the small
reported parameters (sensitivity, specificity, or predictive values)
number of studies for each index test. We had proposed to exclude
was used to inform the 2 × 2 table, yielding true-positive, false-
low-quality studies and possibly reporting a delay in time between
positive, true-negative, and false-negative values. From available
index and reference tests due to potential changes in patient
information, sensitivities, specificities, and their 95% confidence
consciousness and cognitive state.
intervals were calculated by RevMan 5 and plotted in forest plots
and summary receiver operating characteristic (SROC) plots. In
the absence of sufficient data, to calculate the 2 × 2 tables, we
contacted study authors for further information. If this information
Informed decisions.
Assessment of reporting bias stroke. The median sample size was 100, with an interquartile range
(IQR) of 50 to 161; 16 (48%) screening tools had a sample size less
Since no methods are available to quantify publication bias in
than 100.
diagnostic test accuracy reviews, we did not conduct an assessment
of reporting bias. For 16 (43%) tests, admission to index test time was ≤ 24 hours, for
six (16%) between 24 hours and 72 hours, and for two (5%) ≥ 72
RESULTS hours; for 13 (35%), this information was not recorded. For 28 (76%)
tests the index test was applied before the reference test, for one
Results of the search
(3%) the reference test was applied before the index test, for five
We conducted two searches - the first in June 2017 and the (14%) the order was not specified or mixed, and for three (8%) this
same search in December 2019. We identified 26,701 papers was not recorded. The time interval between index and reference
through database searches, and we found two additional studies tests was ≤ 24 hours for 18 (49%) tests, was > 24 hours for 10 (27%)
by handsearching the references of existing systematic reviews, tests, and was not recorded for nine (24%) tests.
for a total of 20,567 articles once duplicates were removed. After
titles and abstracts of articles had been screened, we assessed Twenty-four (64.9%) screening tools used water only (Behera
the full texts of 233 articles against the eligibility criteria. Of these, 2018a; Behera 2018b; Cummings 2015; Daniels 1997; Daniels 2016a;
we excluded 208 articles - 35 because they did not compare Daniels 2016b; Edmiaston 2010a; Edmiaston 2010b; Edmiaston
appropriate index and reference tests, 24 because they did not 2014a; Edmiaston 2014b; Eren 2019; Huhn-Matesic 2015; Jiang
involve consecutive acute stroke patients, 16 because they did not 2019a; Jiang 2019b; Lim 2001b; Martino 2009 Study 1; Martino
relate to screening for dysphagia, eight because index tests were 2014; Mulheren 2019; Nishiwaki 2005; Perry 2001 Study 1a; Perry
carried out by experts, three because they involved only patients 2001 Study 1b; Warnecke 2008a; Warnecke 2008b; Zhou 2011), six
with dysphagia or aspiration and so sensitivity and specificity (16.2%) used water and other consistencies (Campbell 2016; Ellis
could not be calculated, two because they were not single-gate 2013; Huhmann 2004; Perry 2001 Study 1c; Perry 2001 Study 1d;
or two-gate studies, and one because not all patients received Trapl 2007b), and seven (18.9%) used other methods. The other
the same reference test (see Characteristics of excluded studies). methods were evaluation of patient characteristics only (Antonios
Additionally, we excluded 57 references that were conference 2010a; Antonios 2010b; Bravata 2009a), notes review (Bravata
abstracts, 38 that were not primary research studies, 12 that were 2009b), combined water swallow test and oxygen saturation
duplicate papers, six that had been withdrawn or were unavailable, (Lim 2001a), oxygen saturation (Smith 2000), and evaluation of
three that were research protocols or trial registrations, two that patient characteristics followed by water swallow test and oxygen
were Master's or PhD theses, and one that was not relevant. Twenty- saturation (Turner-Lawrence 2009). Several references reported use
five articles went through to data extraction and were included of more than one screening tool as detailed in Table 2.
in the final review. Four of the included articles did not include
Expert assessment or the Mann Assessment of Swallowing Ability
enough detail for calculating the diagnostic accuracy of the index
(MASA) was utilised for 20 (54.1%) screening tools as the reference
test, thus we included these in narrative descriptions only. More
test (Antonios 2010a; Antonios 2010b; Behera 2018a; Behera 2018b;
detail is shown in the PRISMA diagram (Figure 1).
Bravata 2009a; Bravata 2009b; Campbell 2016; Cummings 2015;
We checked the reference lists of included studies, but this did Edmiaston 2010a; Edmiaston 2010b; Ellis 2013; Huhmann 2004;
not reveal additional eligible papers. Details on participants, index Huhn-Matesic 2015; Jiang 2019a; Jiang 2019b; Perry 2001 Study
tests, reference tests, and sensitivity and specificity of each index 1a; Perry 2001 Study 1b; Perry 2001 Study 1c; Perry 2001 Study
test are displayed in the Characteristics of included studies table. 1d; Turner-Lawrence 2009); six (16.2%) used FEES (Eren 2019; Lim
2001a; Lim 2001b; Trapl 2007b; Warnecke 2008a; Warnecke 2008b),
The 25 included studies investigated a total of 37 screening tools, and 11 (29.7%) used VF (Daniels 1997; Daniels 2016a; Daniels 2016b;
most of which were different tools. All 25 studies are single-gate Edmiaston 2014a; Edmiaston 2014b; Martino 2009 Study 1; Martino
studies. Of 37 screening tools, 21 were used by nurses and 16 2014; Mulheren 2019; Nishiwaki 2005; Smith 2000; Zhou 2011).
by other HCPs. The other HCPs were doctor or physician (n = 6),
dietician (n = 1), neurologist (n = 2), multiple HCPs (n = 4), and HCP We identified 15 (40.5%) screening tools that had an outcome
not recorded (n = 3). Of the 37 screening tools, four could not be of aspiration risk (Behera 2018a; Daniels 1997; Daniels 2016a;
included in an available quantitative analysis as 2 × 2 tables could Daniels 2016b; Edmiaston 2010a; Edmiaston 2014a; Huhn-Matesic
not be constructed to estimate sensitivity or specificity (Eren 2019; 2015; Lim 2001a; Lim 2001b; Nishiwaki 2005; Smith 2000; Trapl
Martino 2014; Nishiwaki 2005; Zhou 2011). Training was given for 2007b; Turner-Lawrence 2009; Warnecke 2008a; Warnecke 2008b),
screening tools used by 17 (81%) nurses and by four (25%) other and we found 20 (54.1%) that had an outcome of dysphagia
HCPs. (Antonios 2010a; Antonios 2010b; Behera 2018b; Bravata 2009a;
Bravata 2009b; Campbell 2016; Cummings 2015; Edmiaston 2010b;
Demographic information and characteristics of all 37 screening Edmiaston 2014b; Ellis 2013; Eren 2019; Huhmann 2004; Jiang
tests (including the four narrative tests) are given in Table 1. When 2019a; Jiang 2019b; Martino 2009 Study 1; Mulheren 2019; Perry
reported, mean age was 58.6 years to 76.8 years, the percentage 2001 Study 1a; Perry 2001 Study 1b; Perry 2001 Study 1c; Perry
of males in the study was 35% to 100%, and the start date of 2001 Study 1d). Only two (5.4%) narrative papers did not record the
study recruitment was between 1995 and 2016. Twenty-two (59%) outcome (Martino 2014; Zhou 2011).
tests were conducted in the USA and Canada, eight (22%) in the
UK and Europe, and six (16%) in other countries; in one (3%)
study, the country was not recorded. Only two (5%) studies used
an established classification system to record the location of the
Informed decisions.
Methodological quality of included studies be at low risk across all four risk of bias domains: patient selection,
index test, reference standard, and flow and timing (Daniels 2016;
Risk of bias Lim 2001; Martino 2009 Study 1; Martino 2014; Trapl 2007; Warnecke
Results of the methodological quality assessment for each of the 25 2008). Two studies were at low risk of bias for three domains (index
included studies are shown in Figure 2. We considered six studies to test, reference standard, and flow and timing) but at uncertain risk
for patient selection (Edmiaston 2014; Mulheren 2019).
Informed decisions.
Figure 2. Risk of bias and applicability concerns summary: review authors' judgements about each domain for each
included study.
Informed decisions.
Figure 2. (Continued)
A major concern for risk of bias across the other included studies swallowing anatomy and physiology (n = 1), clinical signs of
was that they had not enrolled consecutive patients. We identified dysphagia and aspiration (n = 1), and digitised examples of five
12 studies that had enrolled consecutive patients (Antonios 2010; stroke patients with a review of basic anatomy and physiology of
Daniels 1997; Daniels 2016; Jiang 2019; Lim 2001; Martino 2009 swallowing (n = 1). Some index tests reported that training was
Study 1; Martino 2014; Nishiwaki 2005; Perry 2001 Study 1; Smith offered but did not detail the contents (n = 5).
2000; Trapl 2007; Warnecke 2008), but for 12 studies this was
unclear (Behera 2018; Bravata 2009; Campbell 2016; Cummings Synthesis of results
2015; Edmiaston 2010; Edmiaston 2014; Ellis 2013; Eren 2019; The high level of heterogeneity between studies as identified by
Huhmann 2004; Huhn-Matesic 2015; Mulheren 2019; Zhou 2011), the review means that statistical pooling of diagnostic accuracy
and one study employed a convenience sampling method (Turner- data was not possible. We performed a descriptive analysis from
Lawrence 2009). For 11 studies, it is unclear whether inappropriate extracted data (2 × 2 tables) and sensitivity and specificity for all but
exclusions had been avoided when participants were recruited the four screening tests for which this data could not be extracted
(Behera 2018; Bravata 2009; Cummings 2015; Edmiaston 2010; Ellis (Eren 2019; Martino 2014; Nishiwaki 2005; Zhou 2011); these four
2013; Huhmann 2004; Huhn-Matesic 2015; Martino 2014; Perry 2001 studies are not included from this point onwards.
Study 1; Turner-Lawrence 2009; Zhou 2011). Finally, it is unclear in
eight studies whether there had been an appropriate time interval Values for sensitivity and specificity presented here include
between the index test and the reference standard (Behera 2018; the point estimate (95% confidence interval (CI)). The criteria
Bravata 2009; Edmiaston 2010; Ellis 2013; Huhmann 2004; Huhn- of both high sensitivity and high specificity indicate that the
Matesic 2015; Perry 2001 Study 1; Zhou 2011), and it was reported best performing test overall was the Standardized Swallowing
that the time interval was not appropriate in two studies (Daniels Assessment tool (SSA) (Perry 2001 Study 1d) (n = 68), which had
1997; Nishiwaki 2005). sensitivity of 0.97 (95% CI 0.86 to 1.00) and specificity of 0.90 (95%
CI 0.74 to 0.98). However, Perry 2001 Study 1 performed poorly
Applicability concerns on the risk of bias assessment, showing, specifically, high risk of
There were no applicability concerns for 15 studies across the three bias in the flow and timing domain and unclear risk of bias in both
applicability domains: patient selection, index test, and reference index test and reference standard domains, so this result should
standard (Antonios 2010; Bravata 2009; Daniels 2016; Edmiaston be interpreted with caution. Several tests performed better on
2010; Edmiaston 2014; Eren 2019; Jiang 2019; Lim 2001; Martino sensitivity but less well on specificity: the Registered Dietician (RD)
2009 Study 1; Martino 2014; Mulheren 2019; Perry 2001 Study 1; Dysphagia Screening tool (n = 32) had sensitivity of 1.00 (95% CI
Smith 2000; Trapl 2007; Warnecke 2008). However, concern was 0.69 to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97) (Huhmann
high in five studies (Campbell 2016; Cummings 2015; Huhmann 2004); the Bedside Aspiration test (n = 50) had sensitivity of 1.00
2004; Nishiwaki 2005; Turner-Lawrence 2009), and concern was (95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to 0.87)
unclear in four other studies (Behera 2018; Ellis 2013; Huhn-Matesic (Lim 2001a); the Gugging Swallowing Screen (GUSS) (n = 30) had
2015; Zhou 2011), which included patients that did not match sensitivity of 1.00 (95% CI 0.77 to 1.00) with specificity of 0.69 (95%
the review question. Concern that the index test, its conduct, or CI 0.41 to 0.89) (Trapl 2007b); and the Toronto Bedside Swallowing
its interpretation differs from the review question was high in Screening Test (TOR-BSST) (n = 24) had sensitivity of 1.00 (95% CI
Huhmann 2004 and unclear in four studies (Daniels 1997; Huhn- 0.75 to 1.00) with specificity of 0.64 (95% CI 0.31 to 0.89) (Martino
Matesic 2015; Nishiwaki 2005; Zhou 2011). 2009 Study 1).
Findings Of the best performing screening tests, we have the most

confidence in the following studies: Bedside Aspiration test (Lim
Healthcare professionals’ level of training across studies 2001a), GUSS (Trapl 2007b), and TOR-BSST (Martino 2009 Study 1),
The level of training for healthcare professionals undertaking which we rated as having low risk of bias across all four QUADAS-2
the index test in dysphagia and/or use of the index test was risk of bias domains. Of those with low risk of bias, the best
underreported, with only 21 of 37 screening tests stating that performing screening test using only water was TOR-BSST (Martino
training was offered. Of those that detailed the training, there was 2009 Study 1), and the best performing screening test using water
variation in both length and content. Some index tests required 10 plus other consistencies was GUSS (Trapl 2007b). A description
minutes of training (n = 4), some took several hours (n = 3), and of these tests is provided in Appendix 8. However, all of these
two detailed two days of training. The content of training varied screening tools had small sample sizes (n < 100), which limits
between training to use the test plus element of competence (n = 5), interpretation of the estimates of reliability of these tests.
instructions on how to use the index test (n = 4), instructions with Screening tests were grouped into general categories according
a practice component (n = 2), training in anatomy and physiology to taxonomy (water only tests, water plus other consistencies
of swallowing, identification and management of dysfunction and tests, and other tests), healthcare professionals who administered
five successful practice assessments (n = 2), on-line training in the test (nurses versus other healthcare professionals), types of
Informed decisions.
outcomes (aspiration versus dysphagia), and types of reference 6). This informed the descriptive analysis, but no meta-analysis was
standards (expert assessment or MASA versus VF versus FEES), and done because of the small number of studies identified for each
we generated related summary receiver operating characteristic individual screening test.
(ROC) plots using RevMan 5 (see Figure 3; Figure 4; Figure 5; Figure
Figure 3. Summary ROC plot of tests: Grouped by Index taxonomy - water only, water plus bolus and other.
Informed decisions.
Figure 4. Summary ROC plot of tests grouped by index test healthcare professional - nurse and other.
Informed decisions.
Figure 5. Summary ROC plot of tests: grouping index tests by outcome - aspiration and dysphagia.
Informed decisions.
Figure 6. Summary ROC plot of tests: index tests grouped by reference test used - Expert Assessment, FEES and VS.
Type of test (water only tests versus water plus other specificity of 1.00 (95% CI 0.83 to 1.00) to sensitivity of 1.00 (95%
consistencies tests versus other tests) CI 0.75 to 1.00) with specificity of 0.64 (95% CI 0.31 to 0.89)). Those
that used methods other than water only and water and other
Screening tools that used water and other consistencies (accuracy
consistencies had mixed results; some performed as well as the
ranged from sensitivity of 0.75 (95% CI 0.35 to 0.97) with specificity
water-only tests, with the most accurate scoring sensitivity of 1.00
of 0.89 (95% CI 0.75 to 0.97), to sensitivity of 1.00 (95% CI 0.69
(95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to 0.87))
to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97)) generally
(Figure 7). Others performed worse, with the least accurate scoring
were more accurate than screening tests that used only water
having sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity of
(accuracy ranged from sensitivity of 0.46 (95% CI 0.28 to 0.66) with
Informed decisions.
0.84 (95% CI 0.64 to 0.95)). Pooling of data by the screening test n = 627) (Figure 3). However, only six tests used this method.
taxonomy confirmed that screening tests that used water plus Screening tests that used only water had similar accuracy (in terms
other consistencies (participants n = 412) may be more sensitive of sensitivity and specificity) compared with screening tests using
with similar or better specificity than screening tests that used other methods.
water only (participants n = 2914) or other methods (participants
Figure 7. Forest plot of tests grouped by Index Test Taxonomy - Water only, Water plus other consistencies, and
Other tests.
Type of reference standard (expert assessment or MASA versus to 0.87)) or VF (accuracy ranged from sensitivity of 0.46 (95%
VF versus FEES) CI 0.28 to 0.66) with specificity of 1.00 (95% CI 0.83 to 1.00) to
sensitivity of 1.00 (95% CI 0.75 to 1.00) with specificity of 0.64
Screening tools showed better agreement with expert assessment
(95% CI 0.31 to 0.89) (Figure 8). Pooling of screening tests by
or the MASA (accuracy ranged from sensitivity of 0.29 (95% CI 0.08
reference test (Figure 6) confirmed that screening tests that used
to 0.58) with specificity of 0.84 (95% CI 0.64 to 0.95) to sensitivity
expert assessment or the MASA (participants n = 2491) had the
of 1.00 (95% CI 0.69 to 1.00) with specificity of 0.86 (95% CI 0.65
highest accuracy. This may be expected, as the screening tests
to 0.97)) than they did with the instrument-based reference test
will be more closely aligned to expert assessment methods than
of FEES (accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to
to instrumental assessment. Screening tests that used VF as a
0.61) with specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity
reference test had high sensitivity but lower specificity than those
of 1.00 (95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49
using expert assessment or the MASA. However, the number of
Informed decisions.
index tests compared to instrument-based reference tests was low: five were compared to FEES (participants n = 330) and eight were
compared to VF (participants n = 1132).
Figure 8. Forest plot of tests grouped by Reference Test - Expert Assessment and MASA, FEES, and VF.
Type of primary outcome (aspiration versus dysphagia) 1.00 (95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to
0.87)) (Figure 9). Pooling of screening tests by outcome (Figure 5)
Screening tests with dysphagia as the primary outcome (accuracy
showed that screening tests with the greatest accuracy, with both
ranged from sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity
high sensitivity and high specificity, had an outcome of dysphagia
of 0.84 (95% CI 0.64 to 0.95) to sensitivity of 1.00 (95% CI 0.69 to 1.00)
(participants n = 2126). This was to be expected, as dysphagia is
with specificity of 0.86 (95% CI 0.65 to 0.97)) generally performed
more easily observed than aspiration. Several tests that detected
better than screening tests for which the primary outcome was
aspiration risk (participants n = 1827) had high sensitivity but
aspiration (accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to
slightly lower specificity.
0.61) with specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity of
Informed decisions.
Figure 9. Forest plot of tests grouped by Index Test Outcome - aspiration and dysphagia.
Tests designed for nurses compared to tests designed for other (accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to 0.61) with
healthcare professionals specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity of 1.00 (95% CI
0.69 to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97)) (Figure 10).
Screening tools carried out by nurses (accuracy ranged from
Generally, screening tests designed for use by nurses (participants
sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity of 0.84 (95%
n = 2785) performed equally well as those designed for use by other
CI 0.64 to 0.95) to sensitivity of 1.00 (95% CI 0.77 to 1.00) with
HCPs (excluding SLTs) (participants n = 1168) in terms of sensitivity
specificity of 0.69 (95% CI 0.41 to 0.89)) performed consistently
and specificity (Figure 4).
better than those carried out by other HCPs (excluding SLTs)
Informed decisions.
Figure 10. Forest plot of tests grouped by HCP - nurse and other.
Other considerations DISCUSSION

Screening tests with larger sample sizes (n > 200) were Behera Numerous variables need to be systematically reported regarding
2018a, Behera 2018b, Daniels 2016a, Daniels 2016b, Edmiaston training required by the healthcare professional undertaking the
2010a, Edmiaston 2010b, Edmiaston 2014a, and Edmiaston 2014b. swallow screening tool, consistencies offered as part of the tool,
Of these, screening tests with the greatest accuracy (both high and food and drink consistency management options available
sensitivity and high specificity) were Edmiaston 2010a, Edmiaston to the person undertaking the test post screen. From a clinical
2010b, and Edmiaston 2014b. All of these had narrow 95% CIs for perspective, some bedside swallow screening tests are criticised
estimates of sensitivity and specificity. Their lower 95% CIs for for making recommendations for consistencies that have not
sensitivity had a higher value than for some of the overall best been assessed. For example, water-only tests allow normal dietary
performing tests - Lim 2001a, Trapl 2007b, and Martino 2009 Study intake without assessment. Similarly water and other consistency
1. None of the tests with a larger sample size were assessed as low screening tests show a discrepancy between diet and fluid
risk for all four QUADAS-2 risk of bias (ROB) domains. Edmiaston consistencies tested and those recommended. Future studies
2010a and Edmiaston 2010b were unclear for three domains in the should take these concerns into consideration.
ROB and were low for one domain. Edmiaston 2014b was unclear
for one domain in the ROB and was low for the other three domains. Summary of main results
In summary, even though 95% CIs for estimates of sensitivity and
specificity are narrower for the best performing screening tests, This review aimed to summarise the evidence regarding accuracy
which used a larger sample size, their QUADAS-2 risk of bias is not of swallow screening tests to detect aspiration risk associated
as low as that for the overall best performing tests. with dysphagia in acute stroke. Studies did not always report
sufficient information regarding study characteristics; therefore, it
is not possible to explore the influence of sources of heterogeneity.
Informed decisions.
Results show that a number of screening tools offered high assessment, was fundamental before progression to a test of oral
sensitivity. However, we were unable to identify a swallow intake (either various sizes of water bolus or water plus various
screening tool with concomitant high specificity. Furthermore, we consistencies). Generally, water plus various consistencies (n = 6)
were unable to identify a diagnostically accurate swallow screening performed better than water-only tools in terms of sensitivity and
tool that tests a variety of consistencies and offers immediate specificity. The small number of index tests that did not use direct
management advice for healthcare settings that do not have the patient assessment (e.g. used national stroke scales to identify risk
facility to offer expert comprehensive assessments. of swallowing difficulty) did not consistently perform well.
Population and setting Only a few studies gave direction on what food and drink
consistencies should be given to an individual following the
Although this review focused on acute stroke patients, some
screen (e.g. GUSS; Trapl 2007b). These studies will be useful in
studies did not define the time period (from stroke onset or from
healthcare settings, nationally and internationally, when an expert
admission) in which use of swallow screening tool was undertaken.
assessment or an instrumental assessment is not available.
Owing to fluctuation in swallow function within a 24-hour period,
it is incumbent on researchers to specify the time period to The best performing index tests are included in the group carried
direct clinical practice (i.e. use of different screening tools at out by nurses. Index tests carried out by other HCPs are less
different time periods post stroke) and to allow for comparisons of consistent. This may be due to confounding factors regarding the
sensitivity versus other studies. Screening tools that were used in amount of training received by nursing staff within studies rather
the outpatient setting or in the rehabilitation setting were excluded than a reflection on the type of index test or professional group
from the review. undertaking the test. Of the 21 index tests undertaken by nurses, 17
(81.0%) recorded some form of training; for other HCPs, only four
Index tests
(25.0%) papers reported a training element. Furthermore, papers
The ideal balance of sensitivity and specificity may vary according that reported training was required often failed to present the
to the care setting. For example, a very sensitive screening test may elements included in the training. In future studies, the type of
be appropriate for untrained staff who have professional backup training delivered should be reported.
to rapidly identify false-positives. No screening test identified or
excluded swallowing difficulties with perfect accuracy. We were Reference standard
able to identify tests with the best ability to detect people with Reference tests were defined as either expert clinical assessments
and without risk of aspiration from studies providing good quality (usually undertaken by speech and language therapists (SLTs))
evidence. The best performing swallow screening tools were the or instrumental assessments. A variety of reference tests
Bedside Aspiration test (Lim 2001a), the Gugging Swallowing were included to capture patients who could access different
Screen (GUSS) (Trapl 2007b), and the Toronto Bedside Swallowing instrumental assessments. However, the reliability of instrumental
Screening Test (TOR-BSST) (Martino 2009 Study 1). Although assessments used to diagnostically identify aspiration is of clinical
screening tests with larger sample sizes (n > 200) had smaller concern.
confidence intervals (CIs) in estimates of sensitivity and specificity,
they had higher risk of bias than the best performing tests so are Following the SLT opinion, we considered the Mann Assessment
not among the recommended screening tests. For clinicians with a of Swallowing Ability (MASA) as equivalent to an expert clinical
variety of consistencies available, the best performing water plus assessment and included the seven studies that used MASA as a
other consistencies test was GUSS (Trapl 2007b). Although GUSS reference test. Tools that used the MASA or expert assessment for
offers different consistencies as part of the assessment and offers reference testing had a better combined sensitivity and specificity
a consistency management plan for clinicians to implement, the than tools that used instrumental tests of fibreoptic endoscopic
consistencies used are limited to puree, water, and solids, and evaluation of swallowing (FEES) or videofluoroscopy (VF). This may
the test does not include all the consistencies identified in the be due to the similarity between index tests and reference tests of
International Dysphagia Diet Standardised Initiative (International MASA/expert assessment in that both rely on clinical observations
Dysphagia Diet Std Initiative 2017). Therefore, this test may not rather than on instrumental assessment.
be suitable for implementation across all healthcare settings. The
best water-only swallow screening test was TOR-BSST (Martino From summary receiver operating characteristic (SROC) plots,
2009 Study 1). Although all tests demonstrate a combined highest which plot sensitivity versus (1-specificity), index tests that used
sensitivity and specificity and low risk of bias across all domains, FEES as the reference test generally had higher sensitivity but
clinicians should be cautious in their interpretation of these similar specificity than index tests that used VF or MASA as the
findings, as these tests are based on single studies with small reference test combined with expert assessment. Most of the
sample sizes, which limits the interpretation of estimates of studies that used FEES or VF report sensitivity greater than 85% but
reliability for these screening tests. poorer specificity than those that used MASA or expert assessments
as the reference test. No studies were compared to scintigraphy,
Sensitivity is similar for tools with a primary outcome of dysphagia which remains mainly a research tool.
or aspiration, but tools with dysphagia as their outcome perform
better in terms of specificity. This may be due to the greater number Quality of the evidence
of clinical signs of difficulty (e.g. chewing function) that may be The quality of evidence varied across included studies. The
observed in dysphagia compared to aspiration, making it more most common reasons for reduced quality was considerable
easily detected. heterogeneity between studies that affected our ability to combine
and directly compare results.
There is general agreement between index tests that some degree
of behavioural assessment (e.g. alertness), together with oromotor
Informed decisions.
Studies often failed to distinguish between dysphagia and Future research studies should clearly define their primary
aspiration as the primary outcome. Some did not routinely identify outcomes. They should provide more detail regarding participant
time between stroke onset or admission to hospital and time the inclusion and exclusion criteria, and when a study includes
screen was undertaken. Similarly, some studies failed to report individuals with differing underlying aetiologies that precipitate
time between index test and reference test, and the swallow may swallowing difficulties, these data should be reported separately.
have improved or deteriorated in the interval between tests. Many
studies failed to report the training required by different healthcare Future studies should provide greater detail on participant location
professionals to implement the screening tool. and timing of the swallow screening tool used post stroke or
post admission. This, together with a description of participant
Strengths and weaknesses of the review characteristics and swallow severity, would allow researchers to
identify the accuracy of a screening tool within different time
Strengths frames, revealing alterations in swallow function post stroke onset.
This DTA undertook the literature search from an International
perspective and included all relevant studies irrespective of Studies should clarify the reference tests used, and when several
language of publication. Therefore we can be assured that no tests are undertaken, these should be reported separately.
relevant publications were excluded from our searches. We were The level of training provided to healthcare professionals
able to identify the best performing tools within each category of undertaking the index test in dysphagia and/or using the index
swallow screening tools that used water alone, water plus other test has been underreported, and studies that detailed the training
bolus consistencies, and other methods. We included as narrative show variation in both length and content of training. Future
studies trials that did not report statistical results. research should detail the amount and content of training offered
Weaknesses and should examine the impact of training on study fidelity and
outcomes.
Apart from one screening tool that was assessed by two studies,
all remaining screening tools were assessed by single studies. This In addition to technical performance in accurately identifying
hampered the possibility to perform any meaningful meta-analysis. patients with dysphagia with its associated risk of aspiration,
Only descriptive analyses grouped by general categories were bedside swallow screening tools should demonstrate clinical
presented. Studies often failed to distinguish between dysphagia utility. Evaluation of both short-term and long-term participant
and aspiration as the primary outcome. Most studies had small outcomes at defined periods would facilitate assessment of
sample sizes, which limits interpretation of the estimates of whether incidence of aspiration pneumonia, quality of life, and
reliability of the screening tests. Some did not routinely identify participant mortality were influenced by timing of the screening
time between stroke onset or admission to hospital and time the test post stroke or post admission.
screen was undertaken. Similarly, some studies failed to report time
between the index test and the reference test, and the swallow Bedside swallow screening test cost-effectiveness data should
may have improved or deteriorated in the interval between tests. be reported to support healthcare services with clinical
Many studies failed to report the training required by different implementation.
healthcare professionals to implement the screening tool. This has
Future studies should apply the better performing screening tests
had an impact on the quality of this review. We performed no formal
that we have identified, making minor changes in their design
assessment of the overall quality of the evidence, for example, by
to ensure that they have low Quality Assessment of Studies of
using GRADE. We have not included any ongoing studies.
Diagnostic Accuracy (QUADAS-2) risk of bias and using larger
Applicability of findings to the review question sample sizes, rather than continuing to develop local screening
tests. This would build up a body of evidence, would reduce
This review demonstrates that currently, high-quality evidence heterogeneity between screening tests, and ultimately would allow
from research is insufficient to provide conclusive results regarding a meta-analysis of different tests to be conducted.
the accuracy of bedside swallow screening tools in identifying
aspiration associated with dysphagia in the acute stage of stroke. Researchers should be encouraged to consider inclusion of these
issues to when performing future comparative studies.
Applicability of evidence
Agreements and disagreements with other studies or reviews
The review authors are aware of ongoing international studies
that are currently unpublished and are not included as part of This is the largest, most inclusive international and current review
this review. However, this review does identify currently available on identification of risk of aspiration associated with dysphagia as
swallow screening tools that screen with water and those that the main symptom of concern in the acute phase of stroke. Several
screen with a variety of consistencies to offer an ongoing food and recent systematic reviews have explored the accuracy of screening
drink consistency management plan that may be implemented in tools. However, these studies have limited the scope of their review
the clinical setting. owing to the restricted range of languages accepted by the search
(Brodsky 2016; Daniels 2012; Jiang 2016; Oliveira 2001; Schepp
Implications for research 2012), the heterogeneity of included disorders (Brodsky 2016; Jiang
2016; O'Horo 2015), the paucity of information available regarding
High-quality, appropriately statistically powered studies are
the healthcare professional undertaking the study (Brodsky 2016;
needed to evaluate the accuracy of a swallow screening tool in
Chen 2016; Daniels 2012; O'Horo 2015), comparison of only water
identifying aspiration associated with dysphagia in acute stages of
swallow tools (Brodsky 2016; Chen 2016), exclusion of instrumental
stroke.
assessments from reference tests (Jiang 2016), consideration of
Informed decisions.
only dysphagia as the primary outcome (Jiang 2016; Oliveira 2001; Implications for research
Schepp 2012), and specification that no training in dysphagia
should be required (Schepp 2012). However, this current review We have identified the need for high-quality research. Study
had no language restrictions, focuses on acute stages of stroke, authors should be encouraged to include information regarding
identifies the range of healthcare professionals undertaking the patient demographics (including comorbidities that may impact
test, explores the diagnostic accuracy of tools including water outcome and stroke location or classification) and definitions
and water with other consistencies, and includes instrumental and regarding dysphagia and aspiration and time intervals (admission
expert assessments as reference tests with aspiration associated to index test and time from index test to reference test). We
with dysphagia as the focus of the assessment. Therefore, direct recommend that future studies should apply better performing
comparisons are difficult to make. screening tests, enhanced to ensure they have low QUADAS-2 risk
of bias domains, and should use larger sample sizes.
AUTHORS' CONCLUSIONS
ACKNOWLEDGEMENTS
Implications for practice
The review authors acknowledge the contributions of Brigit
This review demonstrates that current high-quality evidence from Chesworth, Kerry Hannah, Dawn Doran, Janet Reed, Hazel Fraser,
research is insufficient to provide conclusive results regarding the and Josh Cheyne.
accuracy of bedside swallow screening tools to identify aspiration
associated with dysphagia in the acute stage of stroke.
Informed decisions.
REFERENCES
References to studies included in this review Ellis 2013 {published data only}
Antonios 2010 {published data only}10.1016/ Ellis AL, Hannibal RR. Nursing swallow screens: why is testing
j.jstrokecerebrovasdis.2009.03.007 water only not enough? Journal of Neuroscience Nursing
2013;45(5):244-53.
Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H,
Hood K, et al. Analysis of a physician tool for evaluating Eren 2019 {published data only}10.5152/NSN.2019.10815
dysphagia on an inpatient stroke unit: the Modified Mann
Eren Y, Karaca EU, Saylam G, Yaylaci A, Alicura S, Çomoğlu SS.
Assessment of Swallowing Ability. Journal of Stroke and
Validity and reliability of the Turkish version of the Barnes-
Cerebrovascular Diseases 2010;19(1):49-57.
Jewish Hospital stroke dysphagia screen test in patients with
Behera 2018 {published data only}10.1016/ acute stroke. Neurological Sciences and Neurophysiology
j.jstrokecerebrovasdis.2018.02.038 2019;36(2):78-83. [DOI: 10.5152/NSN.2019.10815]
Behera A, Read D, Jackson N, Saour B, Alshekhlee D, Huhmann 2004 {published data only}
Mosier AK. A validated swallow screener for dysphagia and
Huhmann M, Decker RT, Byham-Gray L, Maillet JO, VonHagen S.
aspiration in patients with stroke. Journal of Stroke and
Comparison of dysphagia screening by a registered dietitian
Cerebrovascular Diseases 2018;27(7):1897-904. [DOI: 10.1016/
in acute stroke patients to speech language pathologist's
j.jstrokecerebrovasdis.2018.02.038]
evaluation. Topics in Clinical Nutrition 2004;19(3):239-49.
Bravata 2009 {published data only}
Huhn-Matesic 2015 {published data
Bravata DM, Daggett VS, Woodward-Hagg H, Damush T, only}10.1891/1939-2095.8.1.117
Plue L, Russell S, et al. Comparison of two approaches to
Huhn-Matesic EK. Developing and testing a bedside aspiration
screen for dysphagia among acute ischemic stroke patients:
screen to protect stroke patients from aspiration and
nursing admission screening tool versus National Institutes
mortality. Clinical Scholars Review 2015;8(1):117-24. [DOI:
of Health Stroke Scale. Journal of Rehabilitation Research and
10.1891/1939-2095.8.1.117]
Development 2009;46(9):1127-33.
Jiang 2019 {published data only}10.4103/tcmj.tcmj_158_18
Campbell 2016 {published data only}
Jiang J, Yu J, Wang J, Wang Y, Wang W. Evaluation of the
Campbell GB, Carter T, Kring D, Martinez C. Nursing bedside
Chinese version of the swallowing screen in stroke patients
dysphagia screen: is it valid? Journal of Neuroscience Nursing
with dysphagia. Tzu Chi Medical Journal 2019;31(4):270-5. [DOI:
2016;48(2):75-9.
10.4103/tcmj.tcmj_158_18]
Cummings 2015 {published data only}
Lim 2001 {published data only}
Cummings J, Soomans D, O'Laughlin J, Snapp V, Jodoin A,
Lim SHB, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N,
Proco H, et al. Sensitivity and specificity of a nurse dysphagia
Lee SH, et al. Accuracy of bedside clinical methods compared
screen in stroke patients. MEDSURG Nursing 2015;24(4):219-63.
with fiberoptic endoscopic examination of swallowing (FEES)
Daniels 1997 {published data only}10.1044/1058-0360.0604.17 in determining the risk of aspiration in acute stroke patients.
Dysphagia 2001;16(1):1-6.
Daniels SK, McAdam CP, Brailey K, Foundas AL. Clinical
assessment of swallowing and prediction of dysphagia Martino 2009 Study 1 {published data only}10.1161/
severity. American Journal of Speech-Language Pathology STROKEAHA.107.510370
1997;6(4):17-24.
Martino R, Silver F, Teasell R, Bayley M, Nicholson G, Streiner DL,
Daniels 2016 {published data only} et al. The Toronto Bedside Swallowing Screening Test (TOR-
BSST) development and validation of a dysphagia screening
Daniels SK, Pathak S, Rosenbek JC, Morgan RO, Anderson JA.
tool for patients with stroke. Stroke 2009;40(2):555-61.
Rapid aspiration screening for suspected stroke: part 1:
development and validation. Archives of Physical Medicine and Martino 2014 {published data
Rehabilitation 2016;97(9):1440-8. only}10.3109/17549507.2014.902995.
Edmiaston 2010 {published data only} Martino R, Maki E, Diamant N. Identification of dysphagia using
the Toronto Bedside Swallowing Screening Test (TOR-BSST®):
Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a
are 10 teaspoons of water necessary? International Journal of
dysphagia screening tool in acute stroke patients. American
Speech-Language Pathology 2014;16(3):193-8.
Journal of Critical Care 2010;19(4):357-64.
Mulheren 2019 {published data only}10.1016/
Edmiaston 2014 {published data only}
j.apmr.2018.12.032
Edmiaston J, Connor LT, Steger-May K, Ford AL. A simple
Mulheren RW, González-Fernández M. Swallow screen
bedside stroke dysphagia screen, validated against
associated with airway protection and dysphagia after acute
videofluoroscopy, detects dysphagia and aspiration with high
stroke. Archives of Physical Medicine and Rehabilitation
sensitivity. Journal of Stroke and Cerebrovascular Diseases
2019;100(7):1289-93. [DOI: 10.1016/j.apmr.2018.12.032]
2014;23(4):712-6.
Informed decisions.
Nishiwaki 2005 {published data only} Alsibai 2014 {published data only}
Nishiwaki K, Tsuji T, Liu M, Hase K, Tanaka N, Fujiwara T. Alsibai A, Voytas J. Use of electrical stimulation in treatment of
Identification of a simple screening tool for dysphagia in dysphagia, a nursing home experience. Journal of the American
patients with stroke using factor analysis of multiple dysphagia. Geriatrics Society 2014;62:S37.
Journal of Rehabilitation Medicine 2005;37:247-51.
Anderson 2016 {published data only}
Perry 2001 Study 1 {published data only} Anderson JA, Pathak S, Rosenbek JC, Morgan RO, Daniels SK.
Perry L. Screening swallowing function of patients with acute Rapid aspiration screening for suspected stroke: Part 2: initial
stroke. Part one: identification, implementation and initial and sustained nurse accuracy and reliability. Archives of Physical
evaluation of a screening tool for use by nurses. Journal of Medicine and Rehabilitation 2016;97(9):1449-55.
Clinical Nursing 2001;10(4):463-73.
Archer 2015 Study 1 {published data only}
Smith 2000 {published data only} Archer S, Smith C, Newham D. Surface electromyography
Smith HA, Lee SH, O'Neill PA, Connolly MJ. The combination biofeedback in dysphagia therapy: do patients think it helps?
of bedside swallowing assessment and oxygen saturation International Journal of Stroke 2015;10:63.
monitoring of swallowing in acute stroke: a safe and humane
screening tool. Age and Ageing 2000;29(6):495-9. Archer 2015 Study 2 {published data only}
Archer S, Smith C, Newham D. Surface electromyographic
Trapl 2007 {published data only}10.1161/ biofeedback and the effortful swallow exercise for stroke-
STROKEAHA.107.483933 related dysphagia. International Journal of Stroke 2015;10:63.
Trapl M, Enderle P, Nowotny M, Teuschl Y, Matz K,
Dachenhausen A, et al. Dysphagia bedside screening for Armesto 2015 {published data only}
acute-stroke patients: the Gugging Swallowing Screen. Stroke Armesto A, Howald R, Roseman E, Kitchen-Clark T, Convery C,
2007;38(11):2948-52. Boyle K, et al. Swallowing screening in the emergency
department: a collaborative effort to improve patient care.
Turner-Lawrence 2009 {published data only}10.1016/ International Journal of Stroke 2015;10:59-60.
j.annemergmed.2009.03.007
Turner-Lawrence DE, Peebles M, Price MF, Singh SJ, Asimos AW. Aviv 1997 {published data only}
A feasibility study of the Sensitivity of Emergency Physician Aviv JE, Sacco RL, Mohr JP, Thompson JLP, Levin B, Sunshine S,
Dysphagia Screening in acute stroke patients. Annals of et al. Laryngopharyngeal sensory testing with modified barium
Emergency Medicine 2009;54(3):344-8.e1. swallow as predictors of aspiration pneumonia after stroke.
Laryngoscope 1997;107(9):1254-60.
Warnecke 2008 {published data only}10.1136/jnnp.2007.134551
Warnecke T, Teismann I, Meimann W, Olenberg S, Aydogdu 2015 {published data only}
Zimmermann J, Kramer C, et al. Assessment of aspiration risk Aydogdu I, Kiylioglu N, Tarlaci S, Tanriverdi Z, Alpaydin S,
in acute ischaemic stroke - evaluation of the simple swallowing Acarer A, et al. Diagnostic value of "dysphagia limit" for
provocation test. Journal of Neurology, Neurosurgery and neurogenic dysphagia: 17 years of experience in 1278 adults.
Psychiatry 2008;79(3):312-4. Clinical Neurophysiology 2015;126(3):634-43.
Zhou 2011 {published data only} Babi 2014 {published data only}
Zhou Z, Salle JY, Daviet JC, Stuit A, Nguyen CL. Combined Babi MA, Gorman M, Commichau C, Kenney S, Boyle L,
approach in bedside assessment of aspiration risk post stroke: Comeau M, et al. Failed bedside dysphagia screen predicts
PASS. European Journal of Physical and Rehabilitation Medicine pneumonia treatment in acute stroke: a resident quality
2011;47(3):441-6. initiative project in a JC-certified primary stroke center.
Neurology 2014;82(10 Suppl 1).
References to studies excluded from this review Bahia 2014 {published data only}
Addington 1999 Study 1 {published data only} Bahia MM, Mourao LF, Lima FO, Li LM. Clinical predictors of
oropharyngeal dysphagia following acute stroke. Dysphagia
Addington WR, Stephens RE, Gilliland K, Rodriguez M.
2014;29(6):774.
Assessing the laryngeal cough reflex and the risk of developing
pneumonia after stroke. Archives of Physical Medicine and Bahia 2016 {published data only}
Rehabilitation 1999;80(2):150-4.
Bahia MM, Mourao LF, Chun RYS. Dysarthria as a predictor
Addington 1999 Study 2 {published data only} of dysphagia following stroke. NeuroRehabilitation
2016;38(2):155-62.
Addington WR, Stephens RE, Gilliland KA. Assessing
the laryngeal cough reflex and the risk of developing Bax 2013 {published data only}
pneumonia after stroke: an interhospital comparison. Stroke
Bax L, McFarlane M, Green E, Miles A. Introducing a speech and
1999;30(6):1203-7.
language therapy (SLT) led fibre optic endoscopic evaluation
of swallowing (FEES): functional outcomes for acute stroke
patients. International Journal of Stroke 2013;8:40.
Informed decisions.
Bax 2014 {published data only} Crary 2013 Study 1 {published data only}
Bax L, McFarlane M, Green E, Miles A. Speech-language Crary M, Carnaby G, Sura L, Sia I, Rolon S, Levien E, et al.
pathologist-led fiberoptic endoscopic evaluation of swallowing: Spontaneous swallow frequency identifies dysphagia in acute
functional outcomes for patients after stroke. Journal of Stroke stroke. Dysphagia 2013;28(4):612.
and Cerebrovascular Diseases 2014;23(3):e195-e200.
Crary 2013 Study 2 {published data only}
Benjamin 2015 {published data only} Crary M, Carnaby-Mann G, Sura L, Sia I. Spontaneous swallow
Bax L, McFarlane M, Green E, Miles A. Introducing a speech and frequency as a screening protocol for dysphagia in acute stroke.
language therapy (SLT) led fibre optic endoscopic evaluation Neurology 2013;80(1 Meeting Abstracts).
of swallowing (FEES): functional outcomes for acute stroke
patients. International Journal of Stroke 2013;8:40. Crary 2014 Study 1 {published data only}
Crary M, Carnaby G. Multidisciplinary clinical rehabilitation
Burks 2011 {published data only} spontaneous swallow frequency and dysphagia/stroke related
Burks C, Meyer DM. Validation of the TOR-BSST swallow outcomes in acute stroke. International Journal of Stroke
screening tool. Stroke 2011;42(3):e129-e130. 2014;9:220.
Carnaby 2014 {published data only} Crary 2014 Study 2 {published data only}
Carnaby GD. Relationships among videofluoroscopic scales and Crary MA, Carnaby GD, Sia I. Spontaneous swallow frequency
stroke outcome. Dysphagia 2014;29(6):751. compared with clinical screening in the identification
of dysphagia in acute stroke. Journal of Stroke and
Carrington 2013 {published data only} Cerebrovascular Diseases 2014;23(8):2047-53.
Carrington S, Archer S, Smith C. Evaluating the impact of
fibreoptic endoscopic (FEES) evaluation of swallowing with Daniels 2009 {published data only}
dysphagic patients on a stroke unit. International Journal of Daniels SK, Schroeder MF, DeGeorge PC, Corey DM, Foundas AL,
Stroke 2013;8:27. Rosenbek JC. Defining and measuring dysphagia following
stroke. American Journal of Speech-Language Pathology
Chavarria 2015 {published data only} 2009;18(1):74-81.
Chavarria M, Arauz A, Barboza M, Patino M, Becerril M. Scale
for severe dysphagia in lateral medullary stroke. Journal of the Davis-De Geus 2009 {published data only}
Neurological Sciences 2015;357:e108. Davis-De Geus M. Using an evidence-based bedside swallow
screen for all stroke patients: how health care providers can
Choi 2010 {published data only} improve stroke patients' outcomes. Dysphagia 2009;24(4):463.
Choi MG, Sung HY, Kim JS, Cho YK, Park JM, Lee IS, et al.
Usefulness of dysphagia screening protocol including high DePippo 1992 {published data only}
resolution manometry in acute cerebrovascular accident. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz
Gastroenterology 2010;138(5 Suppl 1):S346. water swallow test for aspiration following stroke. Archives of
Neurology 1992;49(12):1259-61.
Chong 2003 {published data only}
Chong MS, Lieu PK, Sitoh YY, Meng YY, Leow LP. Bedside Farneti 2015 {published data only}
clinical methods useful as screening test for aspiration in Farneti D, Prencipe RS, Montano L, Nicolini L, Genovese E.
elderly patients with recent and previous strokes. Annals of the Reliability of screening and bedside procedures in the
Academy of Medicine Singapore 2003;32(6):790-4. management of acute stroke patients in a community hospital.
Dysphagia 2015;30(5):626.
Cichero 2009 {published data only}
Cichero JA, Heaton S, Bassett L. Triaging dysphagia: nurse Giraldo-Cadavid 2015 {published data only}
screening for dysphagia in an acute hospital. Journal of Clinical Giraldo-Cadavid LF, Burguete J, Rueda F, Galvis AM,
Nursing 2009;18(11):1649-59. Castaneda N, Arbulu M, et al. Accuracy of the laryngeal adductor
reflex explored by a new laryngo-pharyngeal esthesiometer
Clayton 2006 {published data only} during the fiberoptic endoscopic evaluation of swallowing.
Clayton J, Jack CIA, Ryall C, Tran J, Hilal E, Gosney M. Tracheal American Journal of Respiratory and Critical Care Medicine
pH monitoring and aspiration in acute stroke. Age and Ageing 2015;191:A2123.
2006;35(1):47-53.
Guerra 2011 {published data only}
Collins 1997 {published data only} Guerra L, Ottaviani C, Grazia Scucchi M, Amendola L,
Collins MJ, Bakheit AMO. Does pulse oximetry reliably Macchiaolo S, Capecchi D, et al. Assessment of dysphagia in
detect aspiration in dysphagic stroke patients? Stroke acute stroke: analysis of degree of agreement between nurses.
1997;28(9):1773-5. L'Infermiere 2011;48(2):e9-13.
Guillén-Solà 2011 {published data only}

Guillén-Solà A, Martínez-Orfila J, Gómez RB, Castelló SM,
Marco E. Screening of swallowing disorders in stroke: utility
Informed decisions.
of clinical signs and clinical examination method of volume- McCullough 2001 {published data only}
viscosity in comparison with videofluoroscopy. Rehabilitacion McCullough GH, Wertz RT, Rosenbek JC. Sensitivity and
2011;45(4):293-300. specificity of clinical/bedside examination signs for detecting
aspiration in adults subsequent to stroke. Journal of
Guillén-Solà 2013 {published data only}
Communication Disorders 2001;34(1-2):55-72.
Guillen-Sola A, Marco E, Martinez-Orfila J, Donaire Mejias MF,
Depolo Passalacqua M, Duarte E, et al. Usefulness of the McCullough 2005 {published data only}
volume-viscosity swallow test for screening dysphagia McCullough GH, Rosenbek JC, Wertz RT, McCoy S, Mann G,
in subacute stroke patients in rehabilitation income. McCullough K. Utility of clinical swallowing examination
NeuroRehabilitation 2013;33(4):631-8. measures for detecting aspiration post-stroke. Journal of
Speech, Language, and Hearing Research 2005;48(6):1280-93.
Gurcay 2018 {published data only}
Gurcay E, Bahceci K, Ozturk E, Yilmaz V, Gundogdu I, Moalli 2016 {published data only}
Ceylan T, et al. Validity and reliability of Turkish version of Moalli D, Dell'Angelo D, Bedard L. CVAS: a rapid dysphagia
the gugging swallowing screen test in the early period of evaluation tool. Connecticut Medicine 2016;80(4):205-7.
hemispheric stroke. Neurological Sciences and Neurophysiology
2018;35(1):6-13. Moon 2010 {published data only}
Moon KH, Sohn HS, Lee ES, Paek EK, Kang EJ, Lee SH, et
Higo 2003 {published data only}
al. Comparison for risk estimate of aspiration between the
Higo R, Tayama N, Watanabe T, Nito T. Pulse oximetry revised dysphagia assessment tool and videofluoroscopy in
monitoring for the evaluation of swallowing function. European post-stroke patients. Journal of Korean Academy of Nursing
Archives of Oto-Rhino-Laryngology 2003;260(3):124-7. 2010;40(3):359-66.
Joundi 2017 {published data only} Mozzanica 2017 {published data only}
Joundi RA, Martino R, Saposnik G, Giannakeas V, Jiming F, Mozzanica F, Scarponi L, Pedrali S, Pizzorni N, Pinotti C, Foieni F,
Kapral MK, et al. Predictors and outcomes of dysphagia et al. Dysphagia screening in subacute care settings using the
screening after acute ischemic stroke. Stroke 2017;48(4):900-6. Italian version of the Royal Brisbane and Women's Hospital (I-
RBWH) dysphagia screening tool [Screening della disfagia nelle
Karaca 2018 {published data only}
unita di cure sub-acute utilizzando la versione italiana del Royal
Karaca Umay E, Gundogdu I, Gurcay E, Ozturk E, Yilmaz V, Brisbane and Women's Hospital (I-RBWH) dysphagia screening
Karaahmet O, et al. The psychometric evaluation of the Turkish tool]. Acta Otorhinolaryngologica Italica 2017;37(1):25-31.
version of the Mann assessment of swallowing ability in
patients in the early period after stroke. Turkish Journal of Murray 2011 {published data only}
Medical Sciences 2018;48(6):1153-61. Murray J, Milich A, Ormerod D. Screening for dysphagia.
Australian Nursing Journal 2011;18(11):44-6.
Logemann 1999 {published data only}
Logemann JA, Veis S, Colangelo L. A screening procedure for NCT00306501 {published data only}
oropharyngeal dysphagia. Dysphagia 1999;14(1):44-51. NCT00306501. Volitional swallowing in stroke patients with
chronic dysphagia. https://clinicaltrials.gov/ct2/show/record/
Mandysova 2015 {published data only}
NCT00306501 (first received 23 March 2006).
Mandysova P, Ehler E, Skvrnakova J, Cerny M, Bartova I,
Pellant A. Development of the Brief Bedside Dysphagia NCT00580138 {published data only}
Screening Test - Revised: a cross-sectional Czech study. Acta NCT00580138. Real-time Internet evaluation of swallowing.
Medica (Hradec Kralove) 2015;58:49-55. https://clinicaltrials.gov/ct2/show/NCT00580138 (first received
24 December 2007).
Marques 2008 {published data only}
Marques CHD, De Rosso ALZ, Andre C. Bedside assessment NCT01765673 {published data only}
of swallowing in stroke: water tests are not enough. Topics in NCT01765673. The Passy Muir Swallowing Self Training Device
Stroke Rehabilitation 2008;15(4):378-83. (PMSST). https://clinicaltrials.gov/ct2/show/NCT01765673 (first
received 10 January 2013).
Martino 2009 Study 2 {published data only}
Martino R, Streiner D, Maki E, Diamant N. A sensitivity analysis NCT02080988 {published data only}
to determine whether ten teaspoons of water are really NCT02080988. Reflexive coughing force in severe aspirators.
necessary. Dysphagia 2009;24(4):473. https://clinicaltrials.gov/ct2/show/NCT02080988 (first received
7 March 2014).
Massey 2002 {published data only}
Massey R, Jedlicka D. The Massey Bedside Swallowing Screen. NCT02848664 {published data only}
Journal of Neuroscience Nursing 2002;34(5):252-60. NCT02848664. Use of the Passy Muir Swallowing Self Trainer.
https://clinicaltrials.gov/ct2/show/NCT02848664 (first received
28 July 2016).
Informed decisions.
NCT03167892 {published data only} Perry 2001 Study 2 {published data only}
NCT03167892. Oral Screens in Post Stroke Training. https:// Perry L. Screening swallowing function of patients with acute
clinicaltrials.gov/ct2/show/NCT03167892 (first received 30 May stroke. Part two: detailed evaluation of the tool used by nurses.
2017). Journal of Clinical Nursing 2001;10(4):474-81.
Nomura 2014 {published data only} Radhakrishnan 2013 {published data only}
Nomura JT, Poole CL, Boyer BW, Papas MA, Thomas J, Radhakrishnan S, Menon UK, Anandakuttan A. A combined
Gregore DR, et al. Customized swallow screening tool to exclude approach of bedside clinical examination and flexible
aspiration pneumonia risk in acute stroke patients. Academic endoscopic evaluation of swallowing in poststroke dysphagia:
Emergency Medicine 2014;21(5 Suppl 1):S257. a pilot study. Annals of Indian Academy of Neurology
2013;16(3):388-93.
Oh 2016 {published data only}
Oh JC, Park JH, Jung MY, Yoo EY, Chang KY, Lee TY. Relationship Rosenbek 2004 {published data only}
between quantified instrumental swallowing examination and Rosenbek JC, McCullough GH, Wertz RT. Is the information
comprehensive clinical swallowing examination. Occupational about a test important? Applying the methods of evidence-
Therapy International 2016;23(1):3-10. based medicine to the clinical examination of swallowing.
Journal of Communication Disorders 2004;37(5):437-50.
Ohira 2013 {published data only}
Ohira M, Ishida R, Maki Y, Okubo M, Sugiyama T, Sakayori T, et Sato 2012 {published data only}
al. Evaluation of swallowing ability using Mann assessment Sato M, Tohara H, Iida T, Wada S, Inoue M, Ueda K. Simplified
of swallowing ability (MASA) of dependent elderly in Japan. cough test for screening silent aspiration. Archives of Physical
Dysphagia 2013;28(4):635. Medicine and Rehabilitation 2012;93(11):1982-6.
Ohira 2017 {published data only} Schrock 2011 {published data only}
Ohira M, Ishida R, Maki Y, Ohkubo M, Sugiyama T, Sakayori T, Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A
Sato T. Evaluation of a dysphagia screening system based novel emergency department dysphagia screen for patients
on the Mann Assessment of Swallowing Ability for use in presenting with acute stroke. Academic Emergency Medicine
dependent older adults. Geriatrics & Gerontology International 2011;18(6):584-9.
2017;17(4):561-7.
Sellars 1998 {published data only}
Osawa 2013 {published data only} Sellars C, Dunnet C, Carter R. A preliminary comparison
Osawa A, Maeshima S, Tanahashi N. Water-swallowing test: of videofluoroscopy of swallow and pulse oximetry in the
screening for aspiration in stroke patients. Cerebrovascular identification of aspiration in dysphagic patients. Dysphagia
Diseases 2013;35(3):276-81. 1998;13(2):82-6.
Ostrofsky 2016 {published data only} Smith Hammond 2009 {published data only}
Ostrofsky C, Seedat J. The South African dysphagia screening Smith Hammond CA, Goldstein LB, Horner RD, Ying J, Gray L,
tool (SADS): a screening tool for a developing context. South Gonzalez-Rothi L, et al. Predicting aspiration in patients with
African Journal of Communication Disorders 2016;63(1):1-9. ischemic stroke: comparison of clinical signs and aerodynamic
measures of voluntary cough. Chest 2009;135(3):769-77.
Palli 2017 {published data only}
Palli C, Fandler S, Doppelhofer K, Niederkorn K, Enzinger C, Sohn 2018 {published data only}
Vetta C, et al. Early dysphagia screening by trained nurses Sohn D, Park G-Y, Koo HJ, Jang YJ, Han Y, Im S. Determining
reduces pneumonia rate in stroke patients: a clinical peak cough flow cutoff values to predict aspiration pneumonia
intervention study. Stroke 2017;48(9):2583-5. among patients with dysphagia using the Citric Acid Reflexive
Cough Test. Archives of Physical Medicine & Rehabilitation
Pennsylvania Patient Safety Authority 2009 {published data 2018;99(12):2532-9.
only}
Pennsylvania Patient Safety Authority. Does your admission Soria 2013 {published data only}
screening adequately predict aspiration risk? Pennsylvania Soria F, Furkim AM, Nunes MC, Pinto G, Lange M, Zetola V.
Patient Safety Authority 2009;6(4):115-21. [http:// Identification risk of aspiration pneumonia in two groups of
patientsafety.pa.gov/ADVISORIES/Pages/200912_115.aspx] patients with stroke. Dysphagia 2013;28(2):325-6.
Perry 2000 {published data only} Stroke and Chewing 2012 {published data only}
Perry L, McLaren SM. Dysphagia screening, assessment and Stroke and chewing. Dental Abstracts 2012;57(3):165.
outcomes in stroke patients: Phase 1 of an evidence-based
practice project. Journal of Clinical Excellence 2000;1(4):201-8. Sung 2018 {published data only}
Sung HY, Lee KS, Choi MG, Kim JS. Dysphagia screening using
high-resolution impedance manometry in acute stroke.
International Journal of Gerontology 2018;12(2):110-5.
Informed decisions.
Sørensen 2013 {published data only} Yeh 2011 {published data only}
Sørensen RT, Rasmussen RS, Overgaard K, Lerche A, Yeh SJ, Huang KY, Wang TG, Chen YC, Chen CH, Tang SC, et al.
Johansen AM, Lindhardt T. Dysphagia screening and intensified Dysphagia screening decreases pneumonia in acute stroke
oral hygiene reduce pneumonia after stroke. Journal of patients admitted to the stroke intensive care unit. Journal of
Neuroscience Nursing 2013;45(3):139-46. the Neurological Sciences 2011;306(1-2):38-41.
Tanuma 2002 {published data only} Zhang 2004 {published data only}
Tanuma S, Sudo E, Takahashi Y, Yoshida A, Kobayashi C, Zhang J, Wang YJ, Cui T. Reliability and validity of nine rating
Ohama Y. The usefulness of the water swallowing test and scales for dysphagia following stroke. Chinese Journal of Clinical
videofluorography in swallowing rehabilitation in patients with Rehabilitation 2004;8(7):1201-3.
cerebrovascular disease. Nippon Ronen Igakkai Zasshi Japanese
Journal of Geriatrics 2002;39(4):427-32.
Additional references
Teramoto 2000 {published data only}
Almeida 2015
Teramoto S, Fukuchi Y. Detection of aspiration and swallowing
Almeida TM, Cola PC, Pernambuco LA, Magalhaes HV Jr,
disorder in older stroke patients: simple swallowing
Silva RG. Screening tools for oropharyngeal dysphagia in stroke.
provocation test versus water swallowing test. Archives of
Audiology - Communication Research 2015;20(4):361-70.
Physical Medicine and Rehabilitation 2000;81(11):1517-9.
Avan 2019
Toscano 2019 {published data only}
Avan A, Digaleh H, Di Napoli M, Stranges S, Behrouz R,
Toscano M, Vigano A, Rea A, Verzina A, Sasso D'Elia T, Puledda F,
Shojaeianbabaei G, et al. Socioeconomic status and stroke
et al. Sapienza Global Bedside Evaluation of Swallowing after
incidence, prevalence, mortality, and worldwide burden: an
Stroke: the GLOBE-3S study. European Journal of Neurology
ecological analysis from the Global Burden of Disease Study.
2019;26(4):596-602.
BMC Medicine 2019;17(191). [DOI: 10.1186/s12916-019-1397-3]
Tuncay 2011 {published data only}
Benfield 2020
Tuncay F, Tasbas Ö, Borman P, Geçene M, Coskun Ö. The
Benfield JK, Everton LF, Bath PM, England TJ. Accuracy
bedside clinical evaluation of swallowing function of stroke
and clinical utility of comprehensive dysphagia screening
patients in acute stage. Journal of Physical Medicine &
assessments in acute stroke: a systematic review and meta-
Rehabilitation Sciences 2011;14(2):33-8.
analysis. Journal of Clinical Nursing 2020;29(9-10):1527-38. [DOI:
Umay 2013 {published data only} 10.1111/jocn.15192]
Umay E, Unlu E, Kilic G, Cakci A, Korkmaz H. Evaluation of Blitzer 1988
dysphagia in early period stroke patients by bedside screening
Blitzer A, Krespi YP, Oppenheimer RW, Levine TM. Surgical
test, endoscopic and electrophysiological methods. Dysphagia
management of aspiration. Otolaryngologic Clinics of North
2013;28(3):395-403.
America 1988;4:743–50.
Virvidaki 2019 {published data only}
Boaden 2011
Virvidaki IE, Giannopoulos S, Nasios G, Dimakopoulos G,
Boaden EE. Improving the identification and management of
Michou E, Milionis H. Predictive value of a novel pragmatic
aspiration after stroke [Doctoral thesis]. University of Central
tool for post-stroke aspiration risk: the Functional Bedside
Lancashire 2011.
Aspiration Screen. Neurogastroenterology and Motility
2019;31(10):e13683. Bray 2016
Warnecke 2017 {published data only} Bray BD, Smith CJ, Cloud GC, Enderby P, James M, Paley L, et al.
The association between delays in screening for and assessing
Warnecke T, Im S, Kaiser C, Hamacher C, Oelenberg S,
dysphagia after acute stroke, and the risk of stroke-associated
Dziewas R. Aspiration and dysphagia screening in acute stroke
pneumonia. Journal of Neurology, Neurosurgery and Psychiatry
- the Gugging Swallowing Screen revisited. European Journal of
2017;88(1):25-30.
Neurology 2017;24(4):594-601.
Brodsky 2016
Weinhardt 2008 {published data only}
Brodsky MB, Suiter DM, Gonzalez-Fernandez M, Michtalik HJ,
Weinhardt J, Hazelett S, Barrett D, Lada R, Enos T, Keleman R.
Frymark TB, Venediktov R, et al. Screening accuracy for
Accuracy of a bedside dysphagia screening: a comparison of
aspiration using bedside water swallow tests: a systematic
registered nurses and speech therapists. Rehabilitation Nursing
review and meta-analysis. Chest 2016;150(1):148-63.
2008;33(6):247-52.
CADTH 2018
Ye 2018 {published data only}
CADTH. Grey matters: a practical tool for searching health-
Ye T, Huang SY, Dong Y, Dong Q. Bedside modified volume-
related grey literature [Internet]. Available from https://
viscosity swallow test might be reliably to predict risk of
www.cadth.ca/resources/finding-evidence 2018.
aspiration pneumonia after stroke. Stroke 2019;50 Suppl
1:AWP479.
Informed decisions.
Chen 2016 Kumar 2010

Chen PC, Chuang CH, Leong CP, Guo SE, Hsin YJ. Systematic Kumar S, Selim MH, Caplan LR. Medical complications after
review and meta-analysis of the diagnostic accuracy of the stroke. Lancet Neurology 2010;9:105-18.
water swallow test for screening aspiration in stroke patients.
Journal of Advanced Nursing 2016;72(11):2575-86. [DOI: Martino 2005
10.1111/jan.13013] Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R.
Dysphagia after stroke: incidence, diagnosis, and pulmonary
Daniels 2012 complications. Stroke 2005;36(12):2756-63.
Daniels SK, Anderson JA, Willson PC. Valid items for screening
dysphagia risk in patients with stroke. Stroke 2012;43(3):892-7. National Stroke Foundation 2010
National Stroke Foundation. Clinical guidelines for stroke
Donovan 2013 management, 2010. https://extranet.who.int/ncdccs/
Donovan NJ, Daniels SK, Edmiaston J, Weinhardt J, Summers D, Data/AUS_D1_Clinical%20Guidelines%20for%20Stroke
Mitchell PH. Dysphagia screening: state of the art: invitational %20Management.pdf.
conference proceeding from the State-of-the-Art Nursing
Symposium, International Stroke Conference 2012. Stroke O'Horo 2015
2013;44(4):e24-31. O’Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J,
Safdar N. Bedside diagnosis of dysphagia: a systematic review.
European Stroke Organisation 2015 Journal of Hospital Medicine 2015;10(4):256-65.
European Stroke Organisation. The European Stroke
Organisation Guidelines: a standard operating procedure. Oliveira 2001
International Journal of Stroke 2015;10(SA100):128-35. [DOI: Oliveira I, Mota L, Freitas S, Ferreira P. Dysphagia screening
10.1111/ijs.12583] tools for acute stroke patients available for nurses: a systematic
review. Nursing Practice Today 2019;6(3):103-15. [DOI: 10.18502/
Gupta 2016 npt.v6i3.1253]
Gupta D, Hull ML, Fraser I, Miller L, Bossuyt PMM,
Johnson N, et al. Endometrial biomarkers for the non- Powers 2019
invasive diagnosis ofendometriosis. Cochrane Database of Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM,
Systematic Reviews 2016, Issue 4. Art. No: CD012165. [DOI: Bambakidis NC, Becker K, et al, on behalf of the American
10.1002/14651858.CD012165] Heart Association Stroke Council. Guidelines for the early
management of patients with acute ischemic stroke: 2019
Intercollegiate Stroke Working Party 2012 update to the 2018 guidelines for the early management of
Intercollegiate Stroke Working Party. National Sentinel Stroke acute ischemic stroke: a guideline for healthcare professionals
Clinical Audit 2010. Royal College of Physicians, 2012. from the American Heart Association/American Stroke
Association. Stroke 2019;50:e344–e418. [DOI: 10.1161/
Intercollegiate Stroke Working Party 2016 STR.0000000000000211]
Intercollegiate Stroke Working Party. Intercollegiate Stroke
Working Party National Clinical Guideline for Stroke. 5th Review Manager 2014 [Computer program]
edition. London: Royal College of Physicians, 2016. The Nordic Cochrane Centre, the Cochrane Collaboration
Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: The
International Dysphagia Diet Std Initiative 2017 Nordic Cochrane Centre, the Cochrane Collaboration, 2014.
International Dysphagia Diet Standardisation Initiative.
Complete IDDSI Framework Detailed definitions. 2017. https:// Rofes 2011
iddsi.org/framework/. [http://iddsi.org/framework/] Rofes L, Arreola V, Almirall J. Diagnosis and management of
oropharyngeal dysphagia and its nutritional and respiratory
Jiang 2016 complications in the elderly. Gastroenterology Research and
Jiang JL, Fu SY, Wang WH, Ma YC. Validity and reliability of Practice 2011;2011:13.
swallowing screening tools used by nurses for dysphagia: a
systematic review. Ci Ji Yi Xue Za Zhi 2016;28(2):41-8. [DOI: Schepp 2012
10.1016/j.tcmj.2016.04.006] Schepp K, Tirschwell DL, Miller RM, Longstreth WT Jr.
Swallowing screens after acute stroke: a systematic review.
Johnson 2019 Stroke 2012;43(3):869-71.
Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, et
al. Global, regional, and national burden of stroke, 1990–2016: Teasell 2019
a systematic analysis for the Global Burden of Disease Study Teasell R, Salbach NM, Acerra N, Bastasi D, Carter SL, Fung J,
2016. Lancet Neurology 2019;18(5):439-58. et al, on behalf of the Rehabilitation and Recovery following
Stroke Writing Group. Assessment and Management of
Katan 2018 Dysphagia and Malnutrition following Stroke. In Lindsay MP,
Katan M, Luft A. Global burden of stroke. Seminars in Neurology Mountain A, Gubitz G, Dowlatshahi D, Casaubon L, de Jong
2018;38(2):208-11. A, Smith EE (Editors); on behalf of the Canadian Stroke Best
Informed decisions.
Practices Advisory Committee. Canadian Stroke Best Practice References to other published versions of this review
Recommendations 2019:71-5.
Boaden 2017
WHF 2016 Boaden E, Doran D, Burnell J, Clegg A, Dey P, Hurley M, et al.
World Heart Federation. The global burden of stroke, 2016. Screening for aspiration risk associated with dysphagia in acute
www.world-heart-federation.org/cardiovascular-health/stroke/. stroke. Cochrane Database of Systematic Reviews 2017, Issue 6.
Art. No: CD012679. [DOI: 10.1002/14651858.CD012679]
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Antonios 2010
Patient Sampling Consecutive
Patient characteristics and setting Inclusion criteria: AIS, diagnosed clinically by a neurologist; radi-
ographic (CT or MRI) confirmation of AIS
Exclusion criteria: unresolved dysphagia before stroke; history of

head/neck surgery or trauma that may impact swallowing ability;
any other concomitant neurological disorder that could impact
oropharyngeal swallowing ability
Setting: 1 × tertiary care academic medical centre with a certified

comprehensive stroke centre
Index tests Modified MASA (MMASA)
Target condition and reference standard(s) Dysphagia
MASA
Flow and timing All patients received the index test(s) and reference standard. All
patients were included in the 2 × 2 table
Interventions between index/reference tests: not reported
Interval between tests ≤ 4 hours
Comparative
Notes
Methodological quality
Item Authors' judge- Risk of bias Applicability con-

ment cerns
DOMAIN 1: Patient Selection
Was a consecutive or random sample of patients enrolled? Yes
Did the study avoid inappropriate exclusions? Yes
Was a two-gate design avoided? Yes
Informed decisions.
Antonios 2010 (Continued)
Could the selection of patients have introduced bias? Low risk
Are there concerns that the included patients and setting do Low concern
not match the review question?
DOMAIN 2: Index Test (All tests)
Were the index test results interpreted without knowledge of Yes

the results of the reference standard?
If a threshold was used, was it pre-specified? No
Could the conduct or interpretation of the index test have High risk
introduced bias?
Are there concerns that the index test, its conduct, or inter- Low concern
pretation differ from the review question?
DOMAIN 3: Reference Standard
Is the reference standards likely to correctly classify the target Yes

condition?
Were the reference standard results interpreted without knowl- Yes

edge of the results of the index tests?
Could the reference standard, its conduct, or its interpreta- Low risk
tion have introduced bias?
Are there concerns that the target condition as defined by Low concern
the reference standard does not match the question?
DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and refer- Yes
ence standard?
Did all patients receive the same reference standard? Yes
Were all patients included in the analysis? Yes
Could the patient flow have introduced bias? Low risk
Behera 2018
Patient Sampling All patients were admitted under a standard stroke protocol
Patient characteristics and setting Inclusion criteria: patients admitted to a comprehensive stroke
centre
Exclusion criteria: unclear
Setting: 1 × hospital designated comprehensive stroke centre
Informed decisions.
Behera 2018 (Continued)
Index tests The DePaul Hospital Swallow Screening tool includes a combina-
tion of non-swallow and swallow items. The 8 non-swallow items
(including tests of alertness, presence of a feeding tube, presence
of a tracheostomy tube, presence of drooling, facial asymmetry,
abnormal tongue movement, abnormal vocal quality, and abnor-
mal voluntary cough) are scored, and if patients pass (score ≤ 5),
they progresses onto the 3 oz WST. If patients fail the non-swal-
low items (score ≥ 6), or if they fail the WST (clinical signs of aspira-
tion), they are kept nil by mouth
Target condition and reference standard(s) Two analyses: dysphagia and aspiration risk
MASA
Flow and timing 374 were admitted to the stroke unit; 225 received the DHSS Index
test. The reason for the drop in numbers is not reported. 224 re-
ceived at least 1 MASA assessment 2 × 2 table is reported for 224
patients
Interval between index and reference tests: not reported
Comparative
Notes

ment cerns
Was a consecutive or random sample of patients enrolled? Unclear
Did the study avoid inappropriate exclusions? Unclear
Could the selection of patients have introduced bias? Unclear risk
Are there concerns that the included patients and setting do Unclear

If a threshold was used, was it pre-specified? Yes
Could the conduct or interpretation of the index test have Low risk
introduced bias?
Informed decisions.
Behera 2018 (Continued)

condition?
Were the reference standard results interpreted without knowl- Unclear

Could the reference standard, its conduct, or its interpreta- Unclear risk
Was there an appropriate interval between index test and refer- Unclear
ence standard?
Could the patient flow have introduced bias? Unclear risk
Bravata 2009
Patient Sampling Patients who had received at least 1 Index test plus the reference
test
Patient characteristics and setting Inclusion criteria: discharge diagnosis with ischaemic stroke (ICD9
434.X and 436)
Exclusion criteria: none recorded
Setting: 1 × tertiary care - Department of Veterans Affairs Medical
Centre
Index tests Nurse Screening Tool applied during admission process. NIHSS
applied retrospectively
SLP: expert assessment
Flow and timing Flow is not possible to report. Study reported only on those who
had at least 1 Index test + the reference test
Timing not reported. In fact, study authors list possible time differ-
ences as a limitation
Comparative
Notes QUADAS-2 is different for each index test. Stroke Severity NIHSS
(test2) reported here, as it is the 'worst', compared to the Nurse
Screening Tool (test1)
Informed decisions.
Bravata 2009 (Continued)

ment cerns
Were the index test results interpreted without knowledge of Unclear

Could the conduct or interpretation of the index test have Unclear risk
introduced bias?

condition?

ence standard?
Could the patient flow have introduced bias? High risk
Informed decisions.
Campbell 2016
Patient Sampling Convenience sample
Patient characteristics and setting Inclusion criteria: diagnosis of stroke or TIA; admitted between
8:30am and 4:30pm; no change in initial NIHSS score between
screening by the nurse and evaluation by the speech pathologist
Exclusion criteria: non-stroke and non-TIA admissions; stroke
and TIA admissions after 4:30pm; NIHSS score change from initial
screening by the nurse, and subsequent evaluation performed by
speech pathologist
Setting: 1 × neuroscience unit - part of a Joint Commission Disease
Specific certified stroke centre
Index tests NBDS
SLP: expert assessment
Flow and timing 3 patients not screened by Nurse 2

Interval between index and reference tests: < 1 hour
Comparative
Notes

ment cerns
Are there concerns that the included patients and setting do High

Informed decisions.
Campbell 2016 (Continued)
introduced bias?

condition?

ence standard?
Were all patients included in the analysis? Unclear
Cummings 2015
Patient characteristics and setting Inclusion criteria: medical diagnosis of stroke; age 18 or older;
ability to follow commands
Exclusion criteria: individuals who were NPO for any reason other
than swallowing problems; history of previous swallowing prob-
lems; mechanical ventilation and/or intubation longer than 24
hours during current admission; inability to follow commands
Setting: 2 × hospital - 20-bed medical neurology unit and 9-bed
neurology intermediate care unit
Index tests Nurse dysphagia screen
Dysphagia evaluation by SLP
Flow and timing All patients received index test(s) and reference standard. All pa-
tients were included in 2 × 2 table
Informed decisions.
Cummings 2015 (Continued)

Index to reference tests interval: ≤ 2 hours
Comparative
Notes

ment cerns

introduced bias?

condition?

Are there concerns that the target condition as defined by Unclear

ence standard?
Informed decisions.
Cummings 2015 (Continued)
Daniels 1997
Patient characteristics and setting Inclusion criteria: new neurological deficit; stroke confirmed by
documentation of acute infarct by CT or MRI scan
Exclusion criteria: obtunded and agitated patients; those with pri-
or history of oropharyngeal dysphagia, oropharyngeal structural
damage, or neurological disease other than stroke that may pro-
duce dysphagia
Setting: 1 × Veterans Affairs Medical Center in New Orleans
Index tests Oropharyngeal assessment to include clinical swallowing assess-

ment
Target condition and reference standard(s) Dysphagia severity or risk of aspiration
VSS
tients included in 2 × 2 table apparently, but numbers do not real-
ly add up
Average time between test: 48 hours
Comparative
Notes Flow and timing high risk due to 48-hour average time gap

ment cerns
Informed decisions.
Daniels 1997 (Continued)

If a threshold was used, was it pre-specified? Unclear
introduced bias?
Are there concerns that the index test, its conduct, or inter- Unclear

condition?

Was there an appropriate interval between index test and refer- No

ence standard?
Daniels 2016
Patient characteristics and setting Inclusion criteria: suspected stroke

Exclusion criteria: non-stroke neurological disease; head/neck
structural changes; dysphagia unrelated to stroke; TIA/stroke
ruled out; not competent/no legally authorised representative;
medically unstable; repeat stroke; previously participated in the
study; > 3 weeks from symptom onset; > 5 days from admission;
childbearing potential female; deceased
Setting: 1 × Michael E DeBakey Veterans Affairs Medical Center –
comprehensive stroke centre
Index tests RAS3 and WST from RAS3
Target condition and reference standard(s) Aspiration in patients with suspected stroke
Informed decisions.

VFSS
Flow and timing 8 patients who received the index test were not reported on. Rea-
sons for no VFSS included C-spine surgery evident on X-ray (n = 1)
and no oral intake before surgery (n = 1)
Reasons for exclusion from VFSS analyses included dysphagia his-

tory prior to stroke (n = 2), equipment failure (n = 1), and C-spine
damage (n = 3)
Index to reference test time interval within 2 hours of screening;

mean (SD) 0.49 (0.24) hours
Comparative
Notes

ment cerns

introduced bias?

condition?

Informed decisions.
ence standard?
Were all patients included in the analysis? No
Edmiaston 2010
Patient Sampling Not recorded
Patient characteristics and setting Inclusion criteria: admitted to stroke service

Setting: 1 × Stroke Service at Barnes-Jewish Hospital, Washington
University Medical Centre
Index tests ASDS
Target condition and reference standard(s) Aspiration risk and dysphagia
MASA
tients included in 2 × 2 table
Interval between tests: approximately 24 hours
Comparative
Notes

ment cerns
Informed decisions.
Edmiaston 2010 (Continued)

introduced bias?

condition?

ence standard?
Edmiaston 2014
Patient Sampling Acute stroke patients prospectively enrolled from Barnes-Jewish

Hospital inpatient stroke service (p2)
Patient characteristics and setting Inclusion criteria: clinical diagnosis of stroke (ischaemic or haem-
orrhagic); age ≥ 18 years
Exclusion criteria: decreased level of alertness preventing partic-
ipation in VFSS (defined as a score of 2 on the 'Alertness' compo-
nent of the MASA); physical limitations preventing ability to sit up-
Informed decisions.

right (excluding intubation, or if treating physician had ordered
the patient to have the head of the bed flat); confirmed or suspect-
ed pregnancy
Setting: 1 × Barnes-Jewish Hospital inpatient stroke service (ur-
ban, tertiary care referral centre admitting 1300 stroke patients
annually)
Index tests BJH-SDS
Target condition and reference standard(s) Dysphagia and aspiration
VFSS
Flow and timing Study included 2 tests: 1 for dysphagia and 1 for aspiration. For
the dysphagia test, all patients received the reference test; for the
aspiration test, 2 patients were excluded and did not receive the
reference test
Interval between index and reference test: 0 to 8 hours (mean in-

terval 2 hours)
Comparative
Notes

ment cerns

introduced bias?
Informed decisions.

condition?

ence standard?
Ellis 2013
Patient Sampling Not recorded
Patient characteristics and setting Inclusion criteria: patient suffered stroke or TIA
Exclusion criteria: not recorded
Setting: 1 × small community hospital - certified primary stroke
centre
Index tests Ellis Nursing Bedside Swallowing Screen
Complete dysphagia evaluation by SLT
Flow and timing 53 participants were included, baseline data for 49 participants
are given, and 46 participants received both screening tests. Out-
line data are provided for patients who were excluded or with-
drawn; however numbers do not necessarily specify the difference
between original sample and those receiving the tests
Interval between tests: not reported
Comparative
Notes
Informed decisions.
Ellis 2013 (Continued)

ment cerns

introduced bias?
Is the reference standards likely to correctly classify the target Unclear

condition?
Were the reference standard results interpreted without knowl- No

Could the reference standard, its conduct, or its interpreta- High risk

ence standard?
Did all patients receive the same reference standard? Unclear
Informed decisions.
Eren 2019
Patient Sampling Unclear
Patient characteristics and setting Inclusion criteria: diagnosis of acute stroke based on clinical and MRI
results; aged > 18 years; normal cognitive function (Mini-Mental Test
Score > 24 points)
Exclusion criteria: presence of previous stroke; neurodegenerative or
muscular disease history potentially associated with swallowing disor-
der; malignancy; history of surgery in the head and neck region; bilat-
eral cranial infarction; psychiatric disorder; presence of infectious dis-
ease such as HIV, hepatitis B or C, decompensated heart failure, and
nasal obstruction (exclusion criteria for FEES)
Setting: 1 × neurology department
Index tests Turkish version of BJH-SDS consists of 5 items, each with 2 choices
(i.e. present = yes, absent = no). The first 4 items assess conscious-
ness and asymmetry or weakness in facial, tongue, and palatal mus-
cles. Level of consciousness is assessed by the Glasgow Coma Scale,
and presence of dysarthria is identified together with the use of other
items. The fifth item consists of the 3-oz water test, and the abnormal-
ity was defined as coughing, choking, or breathlessness while swal-
lowing, or wet/gurgled voice after swallowing. The screening tool is a
pass/fail
FEES
Flow and timing It is not clear whether the same number of patients received index and
reference tests
2 × 2 table: not reported
Interventions between index/reference test: not reported
Interval between tests: ≤ 24 hours
Comparative
Notes
Item Authors' judgement Risk of bias Applicability con-

cerns
Informed decisions.
Eren 2019 (Continued)
Are there concerns that the included patients and set- Low concern
ting do not match the review question?
Were the index test results interpreted without knowledge Yes

of the results of the reference standard?
Could the conduct or interpretation of the index test Low risk

have introduced bias?
Are there concerns that the index test, its conduct, or in- Low concern
terpretation differ from the review question?
Is the reference standards likely to correctly classify the tar- Yes

get condition?
Were the reference standard results interpreted without Yes

knowledge of the results of the index tests?
Could the reference standard, its conduct, or its inter- Low risk
pretation have introduced bias?
Are there concerns that the target condition as defined Low concern
by the reference standard does not match the question?
Was there an appropriate interval between index test and Yes

reference standard?
Huhmann 2004
Patient characteristics and setting Inclusion criteria: none recorded

Setting: 1 × admitted to the stroke team
Index tests Registerd Dietician Dysphagia Screening Tool
Target condition and reference standard(s) Dysphagia risk
Informed decisions.
Huhmann 2004 (Continued)

SLT bedside swallow assessment
tients were included in the 2 × 2 table
Comparative
Notes

ment cerns
Could the selection of patients have introduced bias? High risk

introduced bias?
Are there concerns that the index test, its conduct, or inter- High

condition?

Informed decisions.
Huhmann 2004 (Continued)
ence standard?
Huhn-Matesic 2015
Patient characteristics and setting Regional non-critical care stroke unit. Patient inclusion and exclu-
sion criteria not reported
Index tests EHMBAS followed by simple WST; interpretation not reported
Target condition and reference standard(s) MASA
Flow and timing All patients received the index test(s) and reference standard. All
patients were included in the 2 × 2 table
Comparative
Notes

ment cerns

Informed decisions.
Huhn-Matesic 2015 (Continued)
introduced bias?

condition?

ence standard?
Jiang 2019
Patient characteristics and setting Inclusion criteria: diagnosis of stroke, clinical diagnosis from a neurologist,
radiographic (CT or MRI) confirmation of stroke
Exclusion criteria: history of head/neck surgery, trauma; brain tumour that
could influence swallowing abilities; any other concomitant neurological
disorder that could influence oropharyngeal swallowing ability
Setting: 1 × neurology unit
Index tests The 8-item Chinese version of the modified Standardized Swallowing As-
sessment instrument is divided into 2 parts. In part 1, patients must (1) vol-
untarily cough, (2) control saliva, (3) lick top and bottom lips, (4) breathe
freely, and (5) cannot have a wet or hoarse voice. In part 2 (items 6 to 8), pa-
tients are first given 1 mL of water. Problems are identified if no attempts
are made to swallow or water leaks straight out of the mouth, if coughing,
choking, or breathlessness is observed, or if a wet/gurgly voice develops. In
the absence of any problems, the process is repeated with second and third
tests with 1 mL of water. Gradually, increasing volumes ranging from 1 to 10
mL sequential swallowing are used based on patient tolerance. If no prob-
Informed decisions.
Jiang 2019 (Continued)

lems are evident, half a glass of water (75 mL) is administered. The screen-
ing instrument is a pass vs fail procedure
The 6-item Chinese version of the modified Standardized Swallowing As-

sessment includes the following items from the 8-item instrument: items 1,
3, and 5 of the oromotor examinations, and items 6, 7, and 8 of the WST
SLP expert assessment
Flow and timing All patients received both index and reference tests. All patients were in-
cluded in the analysis
Interventions between index/reference tests: none reported
Interval between tests: ≤ 48 hours
Comparative
Notes
Item Authors' judgement Risk of bias Applicability concerns
Was a consecutive or random sample of patients en- Yes

rolled?
Could the selection of patients have introduced Low risk

bias?
Are there concerns that the included patients and Low concern
setting do not match the review question?
Were the index test results interpreted without knowl- Yes

edge of the results of the reference standard?
Could the conduct or interpretation of the index Unclear risk

test have introduced bias?
Are there concerns that the index test, its conduct, Low concern
or interpretation differ from the review question?
Is the reference standards likely to correctly classify Yes

the target condition?
Informed decisions.
Jiang 2019 (Continued)
Were the reference standard results interpreted with- Unclear

out knowledge of the results of the index tests?
Could the reference standard, its conduct, or its in- Unclear risk
terpretation have introduced bias?
Are there concerns that the target condition as de- Low concern
fined by the reference standard does not match the
question?
Was there an appropriate interval between index test Yes

and reference standard?
Lim 2001
Patient characteristics and setting Inclusion criteria: acute stroke patients admitted to stroke unit of
Tan Tock Seng Hospital
Exclusion criteria: severe peripheral vascular disease; conscious-
ness level not sufficient to give informed consent; no CT evidence
of stroke or no significant neurological deficit (e.g. new hemiple-
gia) lasting > 24 hours; insufficient lip seal to retain 10 mL of water
in the mouth
Setting: 1 × stroke unit
Index tests WST and bedside aspiration (combined WST and oxygen satura-
tion test)
Target condition and reference standard(s) Aspiration
FEES
Flow and timing Patient flow is unclear - 58 patients were eligible, 50 patients re-
ceived reference and index tests, 8 patients subsequently declined
FEES
Time interval between tests: < 24 hours for 45 patients; < 48 hours
for 5 people due to 'technical issues'
Comparative
Notes
Informed decisions.
Lim 2001 (Continued)

ment cerns

introduced bias?

condition?

ence standard?
Informed decisions.
Martino 2009 Study 1

Patient Sampling Consecutive. However 1 in 5 patients receiving a negative screen and

all receiving a positive screen on the index test received the refer-
ence test
Patient characteristics and setting Inclusion criteria: newly admitted to hospital; confirmed diagnosis of
brain stem stroke or cerebellar stroke and all other stroke types with
NIHSS score ≥ 4; stroke confirmed from physician’s clinical note, CT
scan or MRI
Exclusion criteria: non-brain stem and non-cerebellar stroke patients
with low NIHSS scores; patients with current respiratory compro-
mise; a non-oral feeding regime; history of non-stroke neurological
disorder; surgery to the head or neck; history of previous oropharyn-
geal dysphagia, dementia, or decreased level of consciousness; not
alert; cannot be supported to sit upright; cannot follow simple in-
structions
Setting: 2 acute settings will be used for analysis, originally 4. Inpa-
tient stroke units at 2 acute (used in data extract) and 2 rehabilitation
tertiary care hospitals (not used in data extract) in southern Ontario
Index tests TOR-BSST
Target condition and reference standard(s) Dysphagia risk
Videofluoroscopic assessment of swallowing
Flow and timing Of the 311 patients recruited, only 103 were from an acute setting,
and of these only 24 received both tests. Remaining patients were
therefore excluded from the analysis

Comparative
Notes

cerns
Are there concerns that the included patients and setting Low concern
do not match the review question?
Informed decisions.
Martino 2009 Study 1 (Continued)

introduced bias?
Are there concerns that the index test, its conduct, or in- Low concern
terpretation differ from the review question?
Is the reference standards likely to correctly classify the tar- Yes

get condition?

Could the reference standard, its conduct, or its interpre- Low risk
tation have introduced bias?
Was there an appropriate interval between index test and Yes

reference standard?
Martino 2014
Patient characteristics and setting Inclusion criteria: eligible and consented stroke patients in the
original study
Exclusion criteria: not reported
Setting: 2 × acute and 2 × rehabilitation facilities
Index tests TOR-BSST
VFSS
Informed decisions.
Martino 2014 (Continued)
Flow and timing All patients recruited received both index and reference tests. All
patients were included in the analysis, but no 2 × 2 table was re-
ported
Interval between tests < 24 hours
Comparative
Notes

ment cerns

introduced bias?

condition?

Informed decisions.
Martino 2014 (Continued)
ence standard?
Mulheren 2019
Patient Sampling Acute stroke patients admitted to the unit
Patient characteristics and setting Inclusion criteria: acute stroke patients on the units
Exclusion criteria: history of swallowing dysfunction or neurological dis-
ease that might lead to swallowing dysfunction; medical compromise
barring transport to fluoroscopy; insufficient level of alertness to follow
directions during VFSS as determined by the care team
Setting: 1 × neuroscience critical and acute care units of a tertiary care fa-
cility
Index tests The Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow
Screen is based on the 3-oz water swallow test by DePippo 1992. The
screen consists of 3 steps: (1) medical history and status; (2) 1 tsp water
swallow with palpation for hyolaryngeal excursion and observation for
signs of aspiration; (3) 3 oz water swallow with palpation for hyolaryn-
geal excursion and observation for signs of aspiration. Observation for
signs of aspiration is continuous during and up to 1 minute after each
water trial. Wet vocal quality is assessed objectively during the vocalisa-
tion trial by trained nurses. Each step is administered sequentially, and
failure of 1 step results in discontinuation and failure of the entire screen
(positive aspiration risk) with nil-by-mouth status and referral to speech
and language pathology for bedside evaluation
VFSS
Flow and timing All patients recruited received both index and reference tests. All patients
were included in the analysis
Comparative
Notes

cerns
Informed decisions.
Mulheren 2019 (Continued)
Was a consecutive or random sample of patients en- Unclear

rolled?
Are there concerns that the included patients and set- Low concern
ting do not match the review question?
Were the index test results interpreted without knowl- Yes

edge of the results of the reference standard?
Could the conduct or interpretation of the index test Low risk

have introduced bias?
Are there concerns that the index test, its conduct, or Low concern
interpretation differ from the review question?
Is the reference standards likely to correctly classify the Yes

target condition?

Could the reference standard, its conduct, or its inter- Low risk
pretation have introduced bias?
Are there concerns that the target condition as de- Low concern
fined by the reference standard does not match the
question?
Was there an appropriate interval between index test Yes

and reference standard?
Nishiwaki 2005
Informed decisions.
Nishiwaki 2005 (Continued)
Patient Sampling Consecutive patients
Patient characteristics and setting Inclusion criteria: stroke was diagnosed with CT or MRI. Patients
presented with ≥ 1 of the following: (1) bilateral or brain stem
stroke; (2) history of aspiration pneumonia or increased sputum
secretion; (3) cough associated with feeding and/or drinking; (4)
weight loss, decreased oral intake, or prolonged feeding times; (5)
complaint of difficulty in swallowing; (6) need for a therapeutic di-
et or non-oral feeding
Exclusion criteria: patients who could not follow commands, who
had a tracheostomy, who had a prior history of oropharyngeal im-
pairment, or who had active respiratory infection
Setting: 5 × university hospital and affiliated hospitals
Index tests Clinical swallowing tests: 6 oromotor examinations
VFSS
Flow and timing All patients recruited received both index and reference tests. All
patients were included in the analysis
Interval between tests < 7 days, but < 24 hours for acute patients
Comparative
Notes

ment cerns

introduced bias?
Informed decisions.
Nishiwaki 2005 (Continued)

condition?

Was there an appropriate interval between index test and refer- No

ence standard?
Perry 2001 Study 1

Patient characteristics and setting Inclusion criteria: admissions with a clinical diagnosis of acute
stroke (ICD 10 codes 160-164, with or without CT confirmation)
Setting: 1 × study wards of Mayday University Hospital (all wards
that normally care for stroke patients with the exception of 2
female care of the elderly wards where another project was in
progress)
Index tests Standardized Swallowing Assessment tool (test 1)
Standardized Swallowing Assessment tool (test 2) (subset of test

1)
Gag reflex (test 3) (subset of test 4)
Gag reflex data from the 20-month audit period used (test 4)
Summative clinical judgement - used VFS when requested by SLT

to clarify decision
Informed decisions.
Perry 2001 Study 1 (Continued)
Flow and timing Flow of patients is unclear from the paper. Although participants
are discussed in the paper, results are presented as episodes. The
results also include repeat screenings for participants; partici-
pants are excluded after recruitment and are not included in the
analysis
Comparative
Notes

ment cerns

introduced bias?

condition?

Informed decisions.
Perry 2001 Study 1 (Continued)
ence standard?
Did all patients receive the same reference standard? No
Smith 2000
Patient characteristics and setting Inclusion criteria: acute haemorrhagic or infarctive stroke; stroke
confirmed by CT scan; age 18 to 90 years
Exclusion criteria: impaired consciousness level; cognitive impair-
ment or receptive dysphasia sufficient to prevent informed con-
sent; inability to sit upright without minimal support; current low-
er respiratory infection; additional neurological condition; termi-
nal illness; any medical condition that precluded VF
Setting: 2 × university teaching hospitals in Manchester
Index tests Smith Bedside Swallowing, pulse oximetry (Minolta Pulsox 7), or
both
Target condition and reference standard(s) Aspiration and penetration
VF
Flow and timing All patients received the index test(s) and the reference standard.
All patients were included in the 2 × 2 table, but for tests 1 and 5,
the 2 × 2 was recovered in the RevMan calculator. This gave test 5
with N = 52, 1 patient missing

Interval between tests ≤ 24 hours (all tests carried out on the same
day)
Comparative
Notes

ment cerns
Informed decisions.
Smith 2000 (Continued)

introduced bias?

condition?

ence standard?
Trapl 2007
Informed decisions.
Trapl 2007 (Continued)
Patient characteristics and setting Inclusion criteria: patients with first-ever acute stroke and sus-
pected dysphagia; admitted to the acute stroke unit on weekdays
between Monday and Thursday
Exclusion criteria: multiple infarcts visible on CT or MRI scan; dys-
phagia of other known cause; somnolence or coma within 24
hours
Setting: 1 × acute stroke unit
Index tests GUSS
FEES
Flow and timing In group 1, 1 patient refused FEES (reference test) and so was not
included in the 2 × 2 table
In group 2, all patients received the index test(s) and the reference
standard. All patients were included in the 2 × 2 table

Comparative
Notes

ment cerns

introduced bias?
Informed decisions.
Trapl 2007 (Continued)

condition?

ence standard?
Turner-Lawrence 2009
Patient characteristics and setting Inclusion criteria: presumptive stroke diagnosis; age ≥ 18 years;
presenting to the emergency department within 24 hours of symp-
tom onset; Glasgow Coma Scale score > 12; hospital admission
Exclusion criteria: non-stroke diagnosis (based on admitting or
consultant physician evaluation); primary brain lesion as cause of
stroke; intubation before completion of ED screening or SLP eval-
uation; history of dysphagia or modified feeding route; pre-exist-
ing neuromuscular disorder; history of head and neck cancer or
radiation; preexisting pneumonia on ED chest radiography; preg-
nancy
Setting: 1 × 850-bed, tertiary-care, TJC-certified, primary stroke
centre located in the southeast
Index tests ED dysphagia screen (2-tiered approach)
SLP dysphagia assessment
All patients were included in the 2 × 2 table
Informed decisions.
Turner-Lawrence 2009 (Continued)
Comparative
Notes

ment cerns
Was a consecutive or random sample of patients enrolled? No
Could the selection of patients have introduced bias? High risk

introduced bias?

condition?

ence standard?
Informed decisions.
Turner-Lawrence 2009 (Continued)
Warnecke 2008
Patient characteristics and setting Inclusion criteria: first-ever stroke; admitted within 24 hours of
onset of symptoms; patients eligible for advanced dysphagia as-
sessment as defined by NIHSS score ≥ 3 points and/or who had to
present with facial palsy and/or dysarthria
Exclusion criteria: patients with history of a pre-existing dysphagia
or disease probably causing dysphagia; severely reduced state of
consciousness (i.e. stupor or coma)
Setting: not recorded
Index tests 2-step Swallowing Provocation Test
FEES
All patients were included in the 2 × 2 table
Interval between tests ≤ 24 hours, reported as immediately follow-
ing
Comparative
Notes

ment cerns

Informed decisions.
Warnecke 2008 (Continued)
introduced bias?

condition?

ence standard?
Zhou 2011
Patient characteristics and setting Inclusion criteria: patients suffering a first-ever hemispheric
stroke; symptoms lasting at least 24 hours; objective lesions on
cerebral imaging (CT and/or MRI) confirmed
Exclusion criteria: patients with subarachnoid haemorrhage, sub-

tentorial stroke or TIA, patients with sufficient loss of conscious-
ness to prevent oral feeding; patients with history of otolaryngo-
logical cancer; < 18 years of age; those who did not expressly agree
to participate in the study
1 × Neurology Department at university hospital. 1 × Department

of Physical Medicine and Readaptation
Index tests Clinical Predicative Scale of Aspiration; Practical Aspiration

Screening Scheme
Informed decisions.
Zhou 2011 (Continued)
Target condition and reference standard(s) Reference standard: videofluoroscopic examination
Flow and timing
Comparative
Notes This paper is classified as narrative

ment cerns

introduced bias?

condition?


ence standard?
Informed decisions.
Zhou 2011 (Continued)
Did all patients receive the same reference standard? Unclear
AIS: acute ischaemic stroke.

ASDS: Acute Stroke Dysphagia Screening.
BJH-SDS: Barnes-Jewish Hospital-Stroke Dysphagia Screen.
CT: computed tomography.
ED: emergency department.
EHMBAS: Edith-Huhn-Matesic Bedside Aspiration Screen.
GUSS: Gugging Swallowing Screen.
MRI: magnetic resonance imaging.
NBDS: Nursing Bedside Dysphagia Screen.
NIHSS: National Institutes of Health Stroke Scale.
NPO: nil by mouth.
RAS3: Rapid Aspiration Screening for Suspected Stroke.
SLP: speech and language pathologist.
TIA: transient ischaemic attack.
TOR-BSST: Toronto Bedside Swallowing Screening Test.
VFSS: videofluoroscopic swallowing study.
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Addington 1999 Study 1 No acute stroke
Addington 1999 Study 2 No acute stroke
Alsibai 2014 No outcome of interest
Anderson 2016 Does not compare tests
Archer 2015 Study 1 No index or reference test of interest
Archer 2015 Study 2 No index or reference test of interest
Armesto 2015 No outcome of interest
Aviv 1997 No outcome of interest
Aydogdu 2015 Not limited to stroke patients
Babi 2014 Does not compare tests
Bahia 2014 Does not compare tests
Bahia 2016 Not an acute setting
Informed decisions.
Bax 2013 Does not compare tests
Bax 2014 No index or reference test of interest
Benjamin 2015 Not a single-gate or 2-gate study
Burks 2011 No screening for dysphagia
Carnaby 2014 No index or reference test of interest
Carrington 2013 Does not compare tests
Chavarria 2015 No screening for dysphagia
Choi 2010 No index or reference test of interest
Chong 2003 Not an acute setting
Cichero 2009 Not limited to stroke patients
Clayton 2006 No index or reference test of interest
Collins 1997 Not an acute setting
Crary 2013 Study 1 No index or reference test of interest
Daniels 2009 Does not compare tests
Davis-De Geus 2009 No outcome of interest
DePippo 1992 Not an acute setting
Farneti 2015 Index test undertaken by experts
Giraldo-Cadavid 2015 No outcome of interest
Guerra 2011 Does not compare tests
Guillén-Solà 2011 No screening for dysphagia
Guillén-Solà 2013 Not an acute setting
Gurcay 2018 Sample not restricted to acute stages of stroke
Higo 2003 No index or reference test of interest
Joundi 2017 Not a single-gate or 2-gate study
Karaca 2018 Reference test MASA considered an SLT dysphagia assessment
Informed decisions.
Logemann 1999 Not limited to stroke patients
Mandysova 2015 Not limited to stroke patients
Marques 2008 Does not compare tests
Martino 2009 Study 2 No index or reference test of interest
Massey 2002 Not all patients received the same reference test
McCullough 2001 SLT dysphagia assessment, not screening
McCullough 2005 No acute stroke
Moalli 2016 Does not compare tests
Moon 2010 No consecutive stroke patients
Mozzanica 2017 Heterogeneous population. Stroke not analysed separately
Murray 2011 No outcome of interest
NCT00306501 No accuracy of screening
NCT00580138 No index or reference test of interest
NCT02080988 No outcome of interest
NCT02848664 Not limited to stroke patients
Nomura 2014 Does not compare tests
Oh 2016 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated
Ohira 2013 Not limited to stroke patients
Ohira 2017 Not an acute setting
Osawa 2013 No consecutive stroke patients
Ostrofsky 2016 Index tests carried out by SLT/SLP
Palli 2017 No reference test performed on same patients who had nurse swallow screen – the compari-
son was with case note data from historic SLT assessment
Pennsylvania Patient Safety Author- Not limited to stroke patients

ity 2009
Perry 2000 Does not compare tests
Perry 2001 Study 2 Does not compare tests
Informed decisions.
Radhakrishnan 2013 No screening for dysphagia
Rosenbek 2004 SLT dysphagia assessment, not screening
Sato 2012 Not an acute setting
Schrock 2011 No index or reference test of interest
Sellars 1998 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated
Smith Hammond 2009 Index tests carried out by SLT/SLP
Sohn 2018 Reference test is a retrospective evaluation of case records
Soria 2013 Not limited to stroke patients
Stroke and Chewing 2012 No outcome of interest
Sung 2018 Does not compare tests
Sørensen 2013 Does not compare tests
Tanuma 2002 Not screening for dysphagia
Teramoto 2000 Not an acute setting
Toscano 2019 Index test undertaken by experts
Tuncay 2011 Not index or reference test of interest
Umay 2013 No acute stroke
Virvidaki 2019 Index test undertaken by experts
Warnecke 2017 Index tests carried out by SLT/SLP
Weinhardt 2008 Does not compare tests
Ye 2018 No reference test was included
Yeh 2011 Does not compare tests
Zhang 2004 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated

SLP: speech and language pathologist.
DATA
Presented below are all the data for all of the tests entered into the review.
Informed decisions.
Table Tests. Data tables by test
Test No. of studies No. of participants
1 Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004) 1 32
2 Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001) 1 50
3 Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007) 1 30
4 Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009) 1 24
5 Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2 1 68
6 Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016) 1 75
7 Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009) 1 84
8 Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010) 1 300
9 Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Ed- 1 223

miaston (2014)
10 Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swal- 1 52

low test - Huhn-Matesic (2015)
11 Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001) 1 161
12 Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia - 1 225

Edmiaston (2014)
13 Modified MASA (MMASA) Neurologist 1 - Antonios (2010) 1 150
14 Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016) 1 250
15 Clinical examination - Daniels (1997) 1 59
16 Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010) 1 300
17 Nurse Dysphagia Screen - Cummings (2015) 1 49
18 Modified MASA (MMASA) Neurologist 2 - Antonios (2010) 1 150
19 Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000) 1 53
20 Bedside swallow test - WST only - Lim (2001) 1 50
21 Chinese version of the modified SSA original 8 items - Jiang (2019) 1 127
22 Chinese version of the modified SSA reduced 6 items - Jiang (2019) 1 127
23 Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) - 1 101
Bravata (2009)
24 Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013) 1 46
25 2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008) 1 100
Informed decisions.
Test No. of studies No. of participants
26 Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels 1 250
(2016)
27 Gag function - Test3 - Perry (2001) 1 22
28 DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera 1 226
(2018)
29 DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018) 1 225
30 Gag function - Test4 - Perry (2001) 1 157
31 2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008) 1 100
32 Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen - 1 48

Mulheren (2019)
33 Nursing Screening Tool - Bravata (2009) 1 39
34 Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish ver- 1 0

sion (T-BJH) - Eren (2019)
35 Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011) 1 0
36 TOR-BSST water swallow item - Martino (2014) 1 0
37 Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005) 1 0
38 Index taxonomy - water only 13 2914
39 Index taxonomy - water plus other consistencies 5 412
40 Index taxonomy - other 5 627
41 Outcome - aspiration 11 1827
42 Outcome - dysphagia 13 2126
43 Reference test - Expert Assessment and MASA 12 2491
44 Reference test - FEES 3 330
45 Reference test - VF 6 1132
46 HCP - nurse 14 2785
47 HCP - other 8 1168
Informed decisions.
Test 1. Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004)
Test 2. Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001)
Test 3. Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007)
Test 4. Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009)
Test 5. Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2
Test 6. Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016)
Informed decisions.
Test 7. Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009)
Test 8. Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010)
Test 9. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Edmiaston (2014)
Test 10. Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swallow test - Huhn-Matesic (2015)
Test 11. Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001)
Test 12. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia - Edmiaston (2014)
Informed decisions.
Test 13. Modified MASA (MMASA) Neurologist 1 - Antonios (2010)
Test 14. Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016)
Test 15. Clinical examination - Daniels (1997)
Test 16. Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010)
Test 17. Nurse Dysphagia Screen - Cummings (2015)
Test 18. Modified MASA (MMASA) Neurologist 2 - Antonios (2010)
Informed decisions.
Test 19. Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000)
Test 20. Bedside swallow test - WST only - Lim (2001)
Test 21. Chinese version of the modified SSA original 8 items - Jiang (2019)
Test 22. Chinese version of the modified SSA reduced 6 items - Jiang (2019)
Test 23. Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) - Bravata (2009)
Test 24. Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013)
Informed decisions.
Test 25. 2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008)
Test 26. Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels (2016)
Test 27. Gag function - Test3 - Perry (2001)
Test 28. DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera (2018)
Test 29. DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018)
Test 30. Gag function - Test4 - Perry (2001)
Informed decisions.
Test 31. 2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008)
Test 32. Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen - Mulheren (2019)
Test 33. Nursing Screening Tool - Bravata (2009)
Test 34. Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish version (T-BJH) - Eren (2019)
Test 35. Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011)
Test 36. TOR-BSST water swallow item - Martino (2014)
Informed decisions.
Test 37. Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005)
Test 38. Index taxonomy - water only
Test 39. Index taxonomy - water plus other consistencies
Test 40. Index taxonomy - other
Informed decisions.
Test 41. Outcome - aspiration
Test 42. Outcome - dysphagia
Informed decisions.
Test 43. Reference test - Expert Assessment and MASA
Test 44. Reference test - FEES
Test 45. Reference test - VF
Informed decisions.
Test 46. HCP - nurse
Test 47. HCP - other
ADDITIONAL TABLES
Table 1. Description of screening tests

Tests (percentage)
(n = 37 tests)
Complete or narrative Complete - 2 × 2 table data extracted 33 (89%)
Narrative - 2 × 2 table data not available 4 (11%)
Participants
Na Median (IQR) 100 (50 to 161) Min = 22, max = 300
Informed decisions.
Table 1. Description of screening tests (Continued)
N with dysphagia/aspira- Median (IQR) 38 (17 to 63) Min = 8, max = 106

tiona
Mean age Median (IQR) 67.6 (64.75 to 71.4) Min = 58.6, max = 76.8
Sex % male Median (IQR) 54.7 (49 to 65.6) Min = 35, max = 100
Year recruitment started Min = 1995, max = 2016
Country UK and Europe 8 (22%)
USA and Canada 22 (59%)
Other 6 (16%)
Not recorded 1 (3%)
Study design
Admission to index test ≤ 24 hours 16 (43%)
> 24 hours and < 72 hours 6 (16%)
≥ 72 hours 2 (5%)
Not recorded 13 (35%)
Order tests applied Index then reference 28 (76%)
Reference then index 1 (3%)
Mixed or not specified 5 (14%)
Not recorded 3 (8%)
Index/reference time in- ≤ 24 hours 18 (49%)

terval
> 24 hours 10 (27%)
Index test training given Yes 21 (57%)
Index test type Water only 24 (65%)
Water plus other consistencies 6 (16%)
Other 7 (19%)
Index test HCP Nurse 21 (57%)
Other 16 (43%)
Outcome Aspiration 15 (41%)
Informed decisions.
Table 1. Description of screening tests (Continued)
Dysphagia 20 (54%)
NR 2 (5%)
Reference test Expert assessment and MASA 20 (54%)
FEES 6 (16%)
VF 11 (30%)
aUsing complete studies only.

HCP: healthcare professional.
IQR: interquartile range.
Table 2. Index test reference IDs

Test ID Test name
Antonios 2010a Modified MASA (MMASA) Neurologist 1: Antonios 2010
Antonios 2010b Modified MASA (MMASA) Neurologist 2: Antonios 2010
Behera 2018a DePaul Hospital Swallow Screener (DHSS) Aspiration: Behera 2018
Behera 2018b DePaul Hospital Swallow Screener (DHSS) Dysphagia: Behera 2018
Bravata 2009a Nursing Screening Tool: Bravata 2009
Bravata 2009b Stroke Severity using National Institutes of Health Stroke Scale (NIHSS): Bravata 2009
Campbell 2016 Nursing Bedside Dysphagia Screen (NBDS): Campbell 2016
Cummings 2015 Nurse Dysphagia Screen: Cummings 2015
Daniels 1997 Clinical examination: Daniels 1997
Daniels 2016a Rapid Aspiration Screening for Suspected Stroke (RAS3): Daniels 2016
Daniels 2016b Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only: Daniels 2016
Edmiaston 2010a Acute Stroke Dysphagia Screening (ASDS) Aspiration: Edmiaston 2010
Edmiaston 2010b Acute Stroke Dysphagia Screening (ASDS) Dysphagia: Edmiaston 2010
Edmiaston 2014a Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration: Edmiaston 2014
Edmiaston 2014b Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia: Edmiaston 2014
Ellis 2013 Nursing Bedside Swallowing Screen (NBSS): Ellis 2013
Eren 2019 Barnes-Jewish Hospital Stroke Dysphagia Screen – Turkish version (BJH-SDS) or (T-BJH): Eren 2019
Informed decisions.
Table 2. Index test reference IDs (Continued)
Huhmann 2004 Registered Dietitian (RD) Dysphagia Screening tool: Huhmann 2004
Huhn-Matesic 2015 Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) followed by simple water swallow test:
Huhn-Matesic 2015
Jiang 2019a Chinese version of the modified SSA – original 8 items: Jiang 2019
Jiang 2019b Chinese version of the modified SSA – reduced 6 items: Jiang 2019
Lim 2001a Bedside aspiration - Combined WST and Oxygen Saturation: Lim 2001
Lim 2001b Bedside swallow test - WST only: Lim 2001
Martino 2009 Toronto Bedside Swallowing Screening Test (TOR-BSST): Martino 2009 Study 1
Martino 2014 TOR-BSST water swallow item: Martino 2014
Mulheren 2019 Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen: Mulheren 2019
Nishiwaki 2005 Clinical swallowing tests: Nishiwaki 2005
Perry 2001a Gag function - Test3: Perry 2001 Study 1
Perry 2001b Gag function - Test4: Perry 2001 Study 1
Perry 2001c Standardized Swallowing Assessment tool (SSA) - Test1: Perry 2001 Study 1
Perry 2001d Standardized Swallowing Assessment tool (SSA) – Test2: Perry 2001 Study 1
Smith 2000 Oxygen saturation ≥ 2% - Test2 for Aspiration: Smith 2000
Trapl 2007b Gugging Swallowing Screen (GUSS) - Group2: Trapl 2007
Turner-Lawrence 2009 Emergency Department (ED) dysphagia screen: Turner-Lawrence 2009
Warnecke 2008a 2-step swallowing provocation test (SPT) - step 1 - 0.4 mL: Warnecke 2008
Warnecke 2008b 2-step swallowing provocation test (SPT) - step 2 - 2.0 mL: Warnecke 2008
Zhou 2011 Clinical predicative scale of aspiration (CPSA): Zhou 2011
APPENDICES
Appendix 1. MEDLINE search strategy

1. cerebrovascular disorders/ or basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp
cerebral small vessel diseases/ or exp intracranial arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial
hemorrhages/ or stroke/ or exp brain infarction/ or stroke, lacunar/ or vasospasm, intracranial/ or vertebral artery dissection/
2. (stroke$ or poststroke or apoplex$ or cerebral vasc$ or brain vasc$ or cerebrovasc$ or cva$ or SAH).tw.
3. ((brain or cerebr$ or cerebell$ or vertebrobasil$ or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or middle
cerebral artery or MCA$ or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) adj5 (isch?
emi$ or infarct$ or thrombo$ or emboli$ or occlus$ or hypoxi$)).tw.
Informed decisions.
4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli$ or putaminal or putamen or posterior fossa or hemispher$ or subarachnoid) adj5 (h?emorrhag$ or h?
ematoma$ or bleed$)).tw.
5. hemiplegia/ or exp paresis/ or exp Gait Disorders, Neurologic/
6. (hemipleg$ or hemipar$ or paresis or paraparesis or paretic).tw.
7. or/1-6
8. Deglutition/
9. exp Deglutition Disorders/
10. ((swallow$ or deglutit$ or dysphag$) adj3 (disturbance$ or disorder$ or difficult$ or dysfunction$ or impair$ or condition$ or abnormal
$ or damage$ or injur$)).tw.
11. ((swallow$ or deglutit$ or dysphag$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or
diagnos$ or detect$ or hazard or risk or test)).tw.
12. exp Respiratory Aspiration/ or exp Pneumonia, Aspiration/
13. ((inhal$ or aspirat$ or ingest$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or diagnos
$ or detect$ or hazard or risk or test)).tw.
14. Pharynx/ or pharyngeal muscles/ or esophageal sphincter, upper/ or exp Esophagus/
15. ((throat or oesophag$ or esophag$ or pharyn$ or oropharyn$) adj3 (disturbance$ or disorder$ or difficult$ or dysfunction$ or impair
$ or condition$ or abnormal$ or damage$ or injur$)).tw.
16. exp Fluoroscopy/ or bronchoscopy/ or laryngoscopy/ or endoscopy/ or manometry/
17. Fiber Optic Technology/
18. (fluoroscop$ or videofluroscop$ or fluorescence radiation or fluorescent scan$ or fluorophotograph$ or photofluoroscop

$ or radiofluoroscop$ or roentgenfluoroscop$ or bronchoscop$ or bronchial endoscop$ or laryngotracheobronchoscop$ or
tracheobronchoscop$).tw.
19. or/8-18
20. 7 and 19
Appendix 2. Cochrane Central Register of Controlled Trials (CENTRAL)

June 2017 search – was applied to CENTRAL and HTA
December 2019 search –applied separately to CENTRAL and HTA. HTA was only available until March 2018.
ID Search Hits
#1 MeSH descriptor: [Cerebrovascular Disorders] this term only
#2 MeSH descriptor: [Basal Ganglia Cerebrovascular Disease] this term only
#3 MeSH descriptor: [Brain Ischemia] explode all trees
#4 MeSH descriptor: [Carotid Artery Diseases] explode all trees
#5 MeSH descriptor: [Cerebral Small Vessel Diseases] explode all trees
#6 MeSH descriptor: [Intracranial Arterial Diseases] explode all trees
#7 MeSH descriptor: [Intracranial Embolism and Thrombosis] explode all trees
#8 MeSH descriptor: [Intracranial Hemorrhages] explode all trees
#9 MeSH descriptor: [Stroke] explode all trees
Informed decisions.
#10 MeSH descriptor: [Vasospasm, Intracranial] this term only
#11 MeSH descriptor: [Vertebral Artery Dissection] this term only
#12 (stroke* or poststroke or apoplex* or cerebral vasc* or brain vasc* or cerebrovasc* or cva* or SAH):ti,ab,kw (Word variations have been
searched)
#13 ((brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or middle
cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) near/5 (isch?
emi* or infarct* or thrombo* or emboli* or occlus* or hypoxi*)):ti,ab,kw (Word variations have been searched)
#14 ((brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial
or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid) near/5 (h?emorrhag* or h?
ematoma* or bleed*)):ti,ab,kw (Word variations have been searched)
#15 MeSH descriptor: [Hemiplegia] this term only
#16 MeSH descriptor: [Paresis] explode all trees
#17 MeSH descriptor: [Gait Disorders, Neurologic] explode all trees
#18 (hemipleg* or hemipar* or paresis or paraparesis or paretic):ti,ab,kw (Word variations have been searched)
#19 {or #1-#18}
#20 MeSH descriptor: [Deglutition] this term only
#21 MeSH descriptor: [Deglutition Disorders] explode all trees
#22 ((swallow* or deglutit* or dysphag*) near/3 (disturbance* or disorder* or difficult* or dysfunction* or impair* or condition* or abnormal*
or damage* or injur*)):ti,ab,kw (Word variations have been searched)
#23 ((swallow* or deglutit* or dysphag*) near/3 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or
diagnos* or detect* or hazard or risk or test)):ti,ab,kw (Word variations have been searched)
#24 MeSH descriptor: [Respiratory Aspiration] explode all trees
#25 MeSH descriptor: [Pneumonia, Aspiration] explode all trees
#26 ((inhal* or aspirat* or ingest*) near/3 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*
or detect* or hazard or risk or test)):ti,ab,kw (Word variations have been searched)
#27 MeSH descriptor: [Pharynx] this term only
#28 MeSH descriptor: [Pharyngeal Muscles] this term only
#29 MeSH descriptor: [Esophageal Sphincter, Upper] this term only
#30 MeSH descriptor: [Esophagus] explode all trees
#31 ((throat or oesophag* or esophag* or pharyn* or oropharyn*) near/3 (disturbance* or disorder* or difficult* or dysfunction* or impair*
or condition* or abnormal* or damage* or injur*)):ti,ab,kw (Word variations have been searched)
#32 MeSH descriptor: [Fluoroscopy] explode all trees
#33 MeSH descriptor: [Bronchoscopy] this term only
#34 MeSH descriptor: [Laryngoscopy] this term only
#35 MeSH descriptor: [Endoscopy] this term only
#36 MeSH descriptor: [Manometry] this term only
#37 MeSH descriptor: [Fiber Optic Technology] this term only
#38 (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop* or
tracheobronchoscop*):ti,ab,kw (Word variations have been searched)
Informed decisions.
#39 {or #20-#38}
#40 #19 and #39
Appendix 3. Embase search strategy

1. cerebrovascular disease/ or brain disease/ or exp basal ganglion hemorrhage/ or exp brain hemangioma/ or exp brain hematoma/ or
exp brain hemorrhage/ or exp brain infarction/ or exp brain ischemia/ or exp carotid artery disease/ or exp cerebral artery disease/ or exp
cerebrovascular accident/ or exp cerebrovascular malformation/ or exp intracranial aneurysm/ or exp occlusive cerebrovascular disease/
or exp vertebrobasilar insufficiency/
2. (stroke$ or poststroke or apoplex$ or cerebral vasc$ or brain vasc$ or cerebrovasc$ or cva$ or SAH).tw.
3. ((brain or cerebr$ or cerebell$ or vertebrobasil$ or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or middle
cerebral artery or MCA$ or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) adj5 (isch?
emi$ or infarct$ or thrombo$ or emboli$ or occlus$ or hypoxi$)).tw.
4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli$ or putaminal or putamen or posterior fossa or hemispher$ or subarachnoid) adj5 (h?emorrhag$ or h?
ematoma$ or bleed$)).tw.
5. exp hemiplegia/ or exp paresis/ or neurologic gait disorder/
6. (hemipleg$ or hemipar$ or paresis or paraparesis or paretic).tw.
7. or/1-6
8. dysphagia/
9. swallowing/
10. ((swallow$ or deglutit$ or dysphag$) adj3 (disturbance$ or disorder$ or difficult$ or dysfunction$ or impair$ or condition$ or abnormal
$ or damage$ or injur$)).tw.
11. ((swallow$ or deglutit$ or dysphag$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or
diagnos$ or detect$ or hazard or risk or test)).tw.
12. aspiration pneumonia/ or aspiration/
13. acid aspiration/
14. ((inhal$ or aspirat$ or ingest$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or diagnos
$ or detect$ or hazard or risk or test)).tw.
15. exp pharynx/
16. exp esophagus/ or esophagus muscle/ or upper esophagus sphincter/
17. ((throat or oesophag$ or esophag$ or pharyn$ or oropharyn$) adj3 (disturbance$ or disorder$ or difficult$ or dysfunction$ or impair
$ or condition$ or abnormal$ or damage$ or injur$)).tw.
18. fluoroscopy/ or fluoroscopy system/
19. exp bronchoscopy/ or bronchus examination/
20. exp laryngoscope/ or exp laryngoscopy/
21. endoscopy/ or fiberscope endoscopy/ or videoendoscopy/
22. manometry/
23. (fluoroscop$ or videofluroscop$ or fluorescence radiation or fluorescent scan$ or fluorophotograph$ or photofluoroscop

$ or radiofluoroscop$ or roentgenfluoroscop$ or bronchoscop$ or bronchial endoscop$ or laryngotracheobronchoscop$ or
tracheobronchoscop$).tw.
24. or/8-23
25. 7 and 24
Informed decisions.
Appendix 4. CINAHL search strategy

S1 (MH "Cerebrovascular Disorders") OR (MH "Basal Ganglia Cerebrovascular Disease+") OR (MH "Carotid Artery Diseases+") OR (MH
"Cerebral Ischemia+") OR (MH "Cerebral Vasospasm") OR (MH "Intracranial Arterial Diseases+") OR ( (MH "Intracranial Embolism and
Thrombosis") ) OR (MH "Intracranial Hemorrhage+") OR (MH "Stroke") OR (MH "Vertebral Artery Dissections") OR (MH "Stroke Patients")
OR (MH "Stroke Units")
S2 TI ( stroke or poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH ) or AB ( stroke or
poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH)
S3 TI ( brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or

middle cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) N5
TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus*)
S4 AB ( brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or

middle cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) N5
AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus*)
S5 TI ( brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid ) N5 TI ( haemorrhage* or
hemorrhage* or haematoma* or hematoma* or bleed* )
S6 AB ( brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid ) N5 AB ( haemorrhage* or
hemorrhage* or haematoma* or hematoma* or bleed* )
S7 (MH "Hemiplegia") or (MH "Gait Disorders, Neurologic+")
S8 TI ( (hemipleg* or hemipar* or paresis or paretic) ) OR AB ( (hemipleg* or hemipar* or paresis or paretic) )
S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8
S10 (MH "Deglutition") OR (MH "Gagging")
S11 (MH "Deglutition Disorders")
S12 TI ( (swallow* or deglutit* or dysphag*) N5 (disturbance* or disorder* or difficult* or dysfunction* or impair* or condition* or abnormal*
or damage* or injur*) ) OR AB ( (swallow* or deglutit* or dysphag*) N5 (disturbance* or disorder* or difficult* or dysfunction* or impair*
or condition* or abnormal* or damage* or injur*) )
S13 TI ((swallow* or deglutit* or dysphag*) N5 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or
diagnos* or detect* or hazard or risk or test)) OR AB ((swallow* or deglutit* or dysphag*) N5 (scale* or screen* or checklist* or assess* or
exam* or identif* or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test))
S14 (MH "Aspiration")
S15 (MH "Pneumonia, Aspiration")
S16 (MH "Risk for Aspiration (NANDA)")
S17 TI ((inhal* or aspirat* or ingest*) N5 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*
or detect* or hazard or risk or test)) OR AB ((inhal* or aspirat* or ingest*) N5 (scale* or screen* or checklist* or assess* or exam* or identif*
or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test))
S18 (MH "Pharynx+")
S19 (MH "Esophagus")
S20 TI ((throat or oesophag* or esophag* or pharyn* or oropharyn*) N5 (disturbance* or disorder* or difficult* or dysfunction* or impair*
or condition* or abnormal* or damage* or injur*)) OR AB ((throat or oesophag* or esophag* or pharyn* or oropharyn*) N5 (disturbance* or
disorder* or difficult* or dysfunction* or impair* or condition* or abnormal* or damage* or injur*))
S21 (MH "Fiber Optics")
S22 TI ( (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

tracheobronchoscop*) ) OR AB ( (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or
Informed decisions.
photofluoroscop* or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop*

or tracheobronchoscop*) )
S23 S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22
S24 S9 AND S23
Appendix 5. HTA search strategy

1. cerebrovascular disorders/ or exp brain ischemia/ or exp carotid artery diseases/ or exp cerebral small vessel diseases/ or exp intracranial
arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/ or
vasospasm, intracranial/ or vertebral artery dissection/
2. (stroke or strokes or poststroke or cerebral vasc* or brain vasc$ or cerebrovasc* or cva or SAH) any field
3. ((brain or cerebr* or cerebell* or vertebrobasil* or hemisphere* or intracran* or intracerebral or infratentorial or supratentorial or middle
cerebral artery or MCA or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) and (ischemi*
or ischaemi* or infarct* or thrombo* or emboli* or occlus* or hypoxi*)) any field
4. ((brain or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial or

supratentorial or posterior fossa or hemisphere* or subarachnoid) and (haemorrhag* or hemorrhag* or hematoma* or haematoma* or
bleed*)) any field
5. exp paresis/ or exp Gait Disorders, Neurologic/
6. (hemipleg* or paresis or paraparesis or paretic) any field
7. or/1-6
8. Deglutition/
9. exp Deglutition Disorders/
10. ((swallow* or deglutit* or dysphag*) and (disturbance* or disorder* or difficult* or dysfunction* or impair* or condition* or abnormal*
or damage* or injur*)) any field
11. ((swallow* or deglutit* or dysphag*) and (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or
diagnos* or detect* or hazard or risk or test)) any field
12. exp Pneumonia, Aspiration/
13. ((inhal* or aspirat* or ingest*) and (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*
or detect* or hazard or risk or test)) any field
14. Pharynx/ or pharyngeal muscles/ or exp Esophagus/
15. ((throat or oesophag* or esophag* or pharyn* or oropharynx*) and (disturbance* or disorder* or difficult* or dysfunction* or impair*
or condition* or abnormal* or damage* or injur*)) any field
16. exp Fluoroscopy/ or bronchoscopy/ or laryngoscopy/ or endoscopy/ or manometry/
17. (fluoroscop* or videofluoroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

tracheobronchoscop*) any field
18. or/8-17
29. 7 and 18
Appendix 6. List of targeted grey literature sources (CADTH, 2018)

• Health Quality Council of Alberta (HQCA) http://hqca.ca/studies-and-reviews/completed-reviews/
• Institut national d’excellence en santé et en services sociaux (INESSS) [formerly AETMIS] http://www.inesss.qc.ca/en/publications/
publications.html
• Manitoba Centre for Health Policy (MCHP) http://mchp-appserv.cpe.umanitoba.ca/deliverablesList.html
• NLCAHR : Newfoundland and Labrador Centre for Applied Health Research. Contextualized Health Research Synthesis Program (CHRSP)
http://www.nlcahr.mun.ca/CHRSP/CompletedCHRSP.php
Informed decisions.
• Ottawa Hospital Research Institute (OHRI) http://www.ohri.ca/ksgroup/publications.asp

• Therapeutics Initiative. Therapeutics Letter http://www.ti.ubc.ca/TherapeuticsLetter
• University of British Columbia. Centre for Health Services and Policy Research http://chspr.ubc.ca/publications/
• World Health Organization Regional Office for Europe. Health Evidence Network (WHO HEN) http://www.euro.who.int/en/data-and-
evidence/evidence-informed-policy-making/publications/by-keyword
• Australian Government. Department of Health and Ageing. Australia and New Zealand Horizon Scanning Network (ANZHSN). http://
www.horizonscanning.gov.au/internet/horizon/publishing.nsf/Content/technologies-assessed-lp-2
• Australian Government Department of Health and Ageing. Medical Services Advisory Committee (MSAC). http://www.msac.gov.au/
internet/msac/publishing.nsf/Content/completed-assessments
• Joanna Briggs Institute (JBI). The Joanna Briggs Institute EBP Database http://connect.jbiconnectplus.org/Search.aspx
• Monash Health. Centre for Clinical Effectiveness (CCE). Centre for Clinical Effectiveness – Publications http://monashhealth.org/health-
professionals/cce/cce-publications/
• Queensland Government (Australia). Health Technology Reference Group. Health Technologies Evaluated-Reports and Briefs (COAG
Health Council). https://www.coaghealthcouncil.gov.au/AHMAC/Health-Technology-Reference-Group/Reports-and-Briefs
• Kenniscentrum voor de Gezondheidszorg / Le Centre d'expertise des soins de santé. Belgian Health Care Knowledge Centre (KCE)
https://kce.fgov.be/en/all-reports
• Sundhedsstyrelsen. Danish Health and Medicines Authority (DHMA). http://sundhedsstyrelsen.dk/en/publications
• Haute Autorité de santé/ French National Authority for Health (HAS). Haute Autorité de santé http://www.has-sante.fr/portail/jcms/
c_946986/en/english-toutes-nos-publications-ligne-principale?portal=r_1457306
• Health Service Executive. Irish Health Repository (Lenus) http://www.lenus.ie/hse/
• De Gezondheidsraad (GR). Health Council of the Netherlands http://www.gezondheidsraad.nl/en/publications
• Zorginstituut Nederland. National Health Care Institute Netherlands https://english.zorginstituutnederland.nl/publications
• Folkehelseinstituttet. Norwegian Institute of Public Health. Publications https://www.fhi.no/en/publ/
• Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS). Agency for Health Quality and Assessment of Catalonia http://
aquas.gencat.cat/ca/publicacions/
• Sahlgrenska Universitetssjukhuset. Sahlgrenska University Hospital. Regional activity-based HTA. https://www.sahlgrenska.se/
forskning/htacentrum/
• Healthcare Improvement Scotland. http://www.healthcareimprovementscotland.org/
• NHS National Institute for Health and Care Excellence (NICE). http://www.nice.org.uk/
• UK Department of Health (NHS). International Resource for Infection Control (INRIC) https://www.nric.org.uk/resources
• Agency for Healthcare Research and Quality (AHRQ). Technology Assessments https://www.ahrq.gov/research/findings/ta/index.html
• Institute for Clinical and Economic Review (ICER). https://icer-review.org/materials/
Appendix 7. QUADAS-2 tool: risk of bias and applicability judgements
Domain 1. Patient selection
1. Risk of bias
Describe methods of patient selection:
· Was a consecutive or random sample of patients enrolled? Yes/No/Unclear
• Was a case-control design avoided? Yes/No/Unclear
• Did the study avoid inappropriate exclusions? Yes/No/Unclear
· Could the selection of patients have introduced bias? RISK: LOW/HIGH/UNCLEAR
1. Concerns regarding applicability
Describe included patients (prior testing, presentation, intended use of index test and setting):
Informed decisions.
(Continued)
Is there concern that the included patients do not match the review question? CONCERN: LOW/HIGH/UN-
CLEAR
Domain 2. Index test(s) (if more than 1 index test was used, please complete for each test)
1. Risk of bias
Describe the index test and how it was conducted and interpreted:
• Were the index test results interpreted without knowledge of results of the reference stan- Yes/No/Unclear
dard?
• If a threshold was used, was it prespecified? Yes/No/Unclear
· Could conduct or interpretation of the index test have introduced bias? RISK: LOW/HIGH/UNCLEAR
Is there concern that the index test, its conduct, or its interpretation differ from the review CONCERN: LOW/HIGH/UN-
question? CLEAR
Domain 3. Reference standard
1. Risk of bias
Describe the reference standard and how it was conducted and interpreted:
• Is the reference standard likely to correctly classify the target condition? Yes/No/Unclear
• Were the reference standard results interpreted without knowledge of results of the index Yes/No/Unclear
test?
· Could the reference standard, its conduct, or its interpretation have introduced bias? RISK: LOW/HIGH/UNCLEAR
Is there concern that the target condition as defined by the reference standard does not CONCERN: LOW/HIGH/UN-
match the review question? CLEAR
Domain 4. Flow and timing
1. Risk of bias
Describe any patients who did not receive the index test(s) and/or reference standard or who were excluded from the 2 ×2 ta-
ble (refer to flow diagram):
Describe the time interval and any interventions between index test(s) and reference standard:
• Was there an appropriate interval between index test(s) and reference standard? Yes/No/Unclear
• Did all patients receive a reference standard? Yes/No/Unclear
• Did patients receive the same reference standard? Yes/No/Unclear
• Were all patients included in the analysis? Yes/No/Unclear
· Could the patient flow have introduced bias? RISK: LOW/HIGH/UNCLEAR
Informed decisions.
Appendix 8. Description of screening tests

Bedside Aspiration Test ( Lim 2001 a)
Stage 1: the Water Swallow Test assessed patient’s ability to swallow 50 mL of water in 10-mL aliquots. The patient is seated upright and
is asked to drink all of the 50 mL. Patients were deemed to be clinically aspirating if they coughed or choked during the water drinking
test or had a change in their voice quality following the swallow. Patients were monitored for these signs of possible aspiration for up to
5 minutes after swallowing.
Stage 2: after a rest period of 10 minutes, the Oxygen Saturation Test was conducted. The finger probe of a Novametrix Oxypleth pulse
oximeter (model 520A) was placed on the index finger of the unaffected hand of the patient, with the patient in an upright position. After
equilibrating for 5 minutes, a baseline oxygen saturation reading was taken. A drop > 2% in arterial oxygen saturation was considered
clinically significant (Collins and Bakheit 1997). Maximum and minimum oxygen saturation readings during and for up to 2 minutes after
swallowing 10 mL of water were noted 3 times, and highest and lowest readings were taken. If oxygen saturation fell by 5% or more,
the test was stopped immediately to stop an additional decline in arterial blood oxygenation levels, especially in patients who may have
compromised pulmonary function. Aspiration was deemed present if overt signs of aspiration and/or oxygen desaturation of 2% or more
was noted.
Gugging Swallowing Screen ( Trapl 2007 b)
The Bedside Gugging Swallow Screen (GUSS) consists of two parts. Part 1, the preliminary assessment, involved a simple saliva swallow
test. Patients who were unable to produce enough saliva because of dry mouth were given saliva spray as a substitute. Vigilance, voluntary
cough, throat clearing, and saliva swallowing were assessed. Part 2 consisted of 3 sequentially performed subtests, starting with semisolid
(thickened distilled water), then liquid (increasing amounts of 3, 5, 10, 20, and 50 mL), and finally solid textures (5 tests with dry bread).
Ten seconds is the time limit for a small solid bolus, including the oral preparatory phase. The test was stopped if 1 of the 4 aspiration signs
(deglutition, cough, drooling, and voice change) was positive. Patients must successfully complete all repetitions in the subtest to achieve
the full score of 5 points. If a subtest results in < 5 points, the examination is stopped and a special oral diet and/or further investigation by
videofluoroscopy or fibreoptic endoscopy is recommended. Diet recommendations are then offered, aligned to the functional oral intake
scale, and are given according to points reached in the GUSS.
The Toronto Bedside Swallow Screening Test ( Martino 2009 Study 1 )
The Toronto Bedside Swallowing Screening Test (TOR-BSST) included the following tests: the Kidd 50 mL water swallow test, pharyngeal
sensation, tongue movement, and general dysphonia split into 2 items - 'voice before' and 'voice after'. A pass/fail response was assigned
to each item, so that failure on any item constitutes a positive screen result and therefore increased risk for dysphagia. Administration
continues only until the first TOR-BSST item is failed.
WHAT'S NEW
Date Event Description
13 July 2021 Amended Paper submitted with amendments in response to reviewers'

comments
HISTORY
Protocol first published: Issue 6, 2017
Date Event Description
26 February 2021 Amended Paper submitted with amendments in response to reviewers'

comments
30 September 2020 Amended Paper submitted
30 January 2017 Amended Protocol amended in response to reviewers' comments
Informed decisions.
CONTRIBUTIONS OF AUTHORS
EB, JB, and LH drafted the review and developed the background section with support from CW. PD, AC, MH, and CW, who also provided
advice regarding the methodological perspective and content. EB, JB, LH, PD, LL, ML, HR, EM, AA, and CW provided support for data
collection and analysis, and MH provided statistical expertise. All review authors commented on all sections of the review and reviewed
the final version prior to submission.
DECLARATIONS OF INTEREST
Elizabeth Boaden: none known.
Jane Burnell: none known.
Lucy Hives: none known.
Paola Dey: "my institution has received funding for consultancies and grants in aid from NHS, government and research charities. I have
also been in receipt of a travel bursary from the organisers of the United European Gastroenterology Week in Berlin in 2006"
Andrew Clegg: none known.
Mary W Lyons: none known.
C Elizabeth Lightbody: none known.
Margaret A Hurley: none known.
Hazel Roddam: none known.
Elizabeth McInnes: none known.
Anne Alexandrov: none known.
Caroline L Watkins: none known.
SOURCES OF SUPPORT
Internal sources
• No sources of support provided
External sources
• No sources of support provided
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

We did not perform meta-analyses, as the number of studies for each individual index test was insufficient, that is, did not include at
least four per group. We have presented only descriptive analyses grouped by general categories. Hence we performed no analysis of the
influence of sources of heterogeneity, no subgroup analysis, and no sensitivity analysis. None of the included studies used scintigraphy
as the reference test. We included studies in which the index test was carried out by any healthcare professionals with the exception of
speech and language therapists (SLTs).
INDEX TERMS
Medical Subject Headings (MeSH)

*Deglutition Disorders [diagnosis] [etiology]; Mass Screening; Reproducibility of Results; Sensitivity and Specificity; *Stroke
[complications]
MeSH check words

Humans

Screening For Aspiration Risk Associated With Dysphagia in Acute Stroke

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Screening For Aspiration Risk Associated With Dysphagia in Acute Stroke

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Cochrane

Screening for aspiration risk associated with dysphagia in acute

[Diagnostic Test Accuracy Review]

Screening for aspiration risk associated with dysphagia in acute stroke

Contact: Elizabeth Boaden, eboaden1@uclan.ac.uk.

Editorial group: Cochrane Stroke Group.

- Patient demographics (e.g. age, gender)

- Definition of dysphagia used by the study

- Low-quality studies identified from the methodological quality checklist

- Type and threshold of index test

- Type of reference test

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Screening for aspiration risk associated with dysphagia in acute stroke

Quality of the evidence

Summary of findings 1. Review criteria and findings

Reference standards Expert assessment, including the MASA

FEES: fibreoptic endoscopic evaluation of swallowing.

Summary of findings 2. Screening tests

Screening test N participants Reference stan- Diagnostic estimates Implications

Water-only tests 2914 (13)

Water plus consistencies tests 412 (5)

Other tests 627 (5)

FEES: fibreoptic endoscopic evaluation of swallowing.

BACKGROUND not), although it is acknowledged there may be different levels of

Figure 1. PRISMA flow diagram.

Findings Of the best performing screening tests, we have the most

Other considerations DISCUSSION

Guillén-Solà 2011 {published data only}

Chen 2016 Kumar 2010

Characteristics of included studies [ordered by study ID]

Patient Sampling Consecutive

Exclusion criteria: unresolved dysphagia before stroke; history of

Setting: 1 × tertiary care academic medical centre with a certified

Index tests Modified MASA (MMASA)

Target condition and reference standard(s) Dysphagia

Interventions between index/reference tests: not reported

Interval between tests ≤ 4 hours

Item Authors' judge- Risk of bias Applicability con-

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes

Did the study avoid inappropriate exclusions? Yes

Was a two-gate design avoided? Yes

Antonios 2010 (Continued)

Could the selection of patients have introduced bias? Low risk

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of Yes

If a threshold was used, was it pre-specified? No

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target Yes

Were the reference standard results interpreted without knowl- Yes

DOMAIN 4: Flow and Timing

Did all patients receive the same reference standard? Yes

Were all patients included in the analysis? Yes

Could the patient flow have introduced bias? Low risk

Behera 2018 (Continued)

Item Authors' judge- Risk of bias Applicability con-

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear

Did the study avoid inappropriate exclusions? Unclear

Was a two-gate design avoided? Yes

Could the selection of patients have introduced bias? Unclear risk

DOMAIN 2: Index Test (All tests)